THE ATLAS OF

HEART DISEASE
AND STROKE

DR JUDITH MACKAY AND DR GEORGE A. MENSAH

Published by the WORLD HEALTH ORGANIZATION
in collaboration with the CENTERS FOR DISEASE
CONTROL AND PREVENTION
 The Atlas of
Heart Disease
and Stroke

World Health Organization

Geneva
 In the same series:

The Tobacco Atlas

Inheriting the World:

The Atlas of Children's Health and the Environment
 The Atlas of
Heart Disease
and Stroke

Dr Judith Mackay and Dr George A. Mensah

Wlith
Dr Shanthi Mendis and Dr Kurt Greenlund

World Health Organization

o
Geneva
 The Atlas of Heart Disease and Stroke World Health Organization 2004

All rights reserved

O

First
published 2004
1 3 5 7 9 10 8 6 4 2

WHO Library Cataloguing-in-Publication Data

Mackav, Judith.
The atlas of heart disease and stroke / Judith Mackay and
George Mensah;
with Shanthi Mendis and Kurt Greenlund.
1 .Heart diseases - 2 Cerebrovascular accident
epidemiology .

epidemiology
3. Risk factors 4. Atlases I. Mensah, George. II. Mendis, Shanthi.
III. Greenlund, Kurt. IV.Title.

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 Contents

Foreword

by Dr LEE Jong- Wook, Director-General, World Health Organization 9

Preface 1 1

Acknowledgements 12
About the authors 1 5

CARDIOVASCULAR DISEASE 16

Types of cardiovascular disease 18

Different types of cardiovascular diseases. Global deaths from
cardiovascular diseases.

Rheumatic fever and rheumatic heart disease 20

Deaths from rheumatic heart disease. Cases of rheumatic heart
disease in children. Deaths
among Aboriginal and non-
Aboriginal populations in Australia.

Part Two: RISK FACTORS 22

Risk factors 24
Overview of modifiable, non-modifiable and "novel" risk

factors. Percentage contribution of leading risk factors to

o o
disease burden.
Contributory factors in coronary heart disease
and ischaemic stroke.

Risk factors start in childhood and youth 26

Tobacco use in youth. Overweight youth. Over
weight trends
in the USA.

Risk factor: blood pressure 28

Average systolic blood pressure worldwide. Trends of high
blood pressure in USA and India. Changes in blood pressure
with age in Gambia, and with education in South Africa.

Risk factor: lipids 30

Cholesterol levels in women worldwide. Trends in cholesterol

levels in
Beijing,
China. Current recommended lipid levels.

Risk factor: tobacco 32

Smoking rates worldwide. Cardiovascular
risks of
smoking and
passive smoking. Smokers' lack of knowledge of the risks.
 Risk factor: physical inactivity 34

Physical activity levels:

energy expenditure in work, leisure and

transport. Time spent seated. Various physical activities with

similar health benefits. Physical inactivity by social class in India.

Participation in sport in Singapore. Motor vehicle ownership

and trends. Ratio of bicycles to cars in China and USA.

9 Risk Factor: obesity 36

Average adult body mass index (BMI) worldwide. Food

consumption trends. Apple shape at
higher risk of CVD
than pear shape.

10 Risk factor: diabetes 38

Prevalence of diabetes worldwide. Diabetes trends to 2030.

1 1 Risk factor: socioeconomic status 40

Socioeconomic influences on cardiovascular risk factors and
diseases. Education, income levels and occupation in Canada,
China, India, Italy,
Saudi Arabia, South Africa, Trinidad and

Tobago,
o 'Uganda
o and USA.

12 Women: a special case? 42

Similar and different risks in women compared with men.

Smoking, physical activity

and hormone replacement therapy.

Part Three: THE BURDEN 44

1 3 Global burden of coronary heart disease 46

Healthy years of life lost to coronary heart disease. Leading

causes of disease burden by sex.

14 Deaths from coronary heart disease 48

Deaths from coronary heart disease. Comparison with other
causes of death. Trends in coronary heart disease.

1 5 Global burden of stroke 50

Healthy years of life lost to stroke. Stroke in young people.

Risks of the oral contraceptive pill.

16 Deaths from stroke 52

Deaths from stroke. Predictors of death from stroke in
Italy.

Comparison with other causes of death.

 Economic costs 54
Cost of cardiovascular diseases and their risk factors in selected

countries, regions
o and worldwide. Price of medications

compared with cheapest crop available. Lifetime costs of

coronary heart disease. Expenditure on cardiovascular
medications. Cost of risk factors.

Part Four: ACTION 56

18 Research 58
Number of publications on cardiovascular research by country.

Regional research. Clinical trials on humans: cardiovascular

diseasecompared with other health problems. Research funding
in the USA: CVD compared with other diseases.

Organizations 60
International and regional
o organizations
o involved with
cardiovascular disease. World conferences on cardiovascular

diseases.

Prevention: personal choices and actions 62

Personal choices in lifestyles and behaviours in children,
adolescents and adults: stopping smoking, eating more fruit and

cereals, reducing salt intake, physical activity, and prevention

and control of obesity and high blood pressure.

Prevention: population and systems approaches 64

Noncommunicable disease prevention and control. Availability
of basic equipment, medical professionals, and availability,

affordability,
and local manufacture of drugs. Use of
medications in stroke and coronary heart disease. Profiles of
Finland, Japan, Mauritius and New Zealand. Dieticians in the
United Kingdom promote healthy eating.

Health education 66
World Heart Day participation, themes and trends.
Medical

physical activities and promotion

activities, of healthy diet.

Giving up smoking: the International Quit and

Win campaign.

Policies and legislation

68
Smoke-free government buildings and private workplaces. The
countries to ratify the
first five WHO
Framework Convention
on Tobacco Control (FCTC). National plans for CVD

prevention and control. Tobacco, food and nutrition legislation.

Smoking ban in the USA led to reduction in heart attacks.
24 Treatment 70
Medication, devices, and operations. Simple secondary

prevention. Proportion of patients reaching blood pressure and

cholesterol treatment goals. Participation in cardiac
rehabilitation. Proportion of people with diabetes treated with

medication or diet. Trends in cardiovascular

operations and
procedures in the USA.

Part Five: THE FUTURE AND THE PAST 72

The future 74
Predictions to 2030 of the cardiovascular disease epidemic, risk

factors, economic costs, research, UN Conventions, technology

and treatment.

Milestones in knowledge of heart and vascular disorders

History of key events, developments and research, including
epidemiology, risk factors, economic costs, inventions and
interventions.

BCE-1852 76
1856-1967 78
1969-2004 80

Part Six: World Tables 82

World data tables 84

Glossary 92
Sources 94
Useful contacts 109
Index 1 1 1
 Foreword

A message from

Dr LEE Jong-Wook
Director- General
World Health Organization
O

11 cart disease and stroke are currently the leading cause of death in all
developed countries and in most developing
countries. There were approximately 17 million deaths due to cardiovascular disease in 2003 one-third of all

deaths in the world.

disturbing to note that at least 75%

It is of deaths from heart disease and stroke now occur in the poorer regions
of the world, which also face major threats from communicable diseases. These regions thus suffer under the so-
called "double burden" of disease. If
preventive action is not taken urgently, heart disease and stroke which are

rapidly advance across regions and

social classes to reach
already major public health problems
will epidemic
proportions worldwide.
We know that the major risk factors for heart disease and stroke are high blood pressure, high blood cholesterol,
tobacco use, physical inactivity, unhealthy diet and obesity. Many of these risk factors result from unhealthy lifestyles.
These unhealthy lifestyle habits,
which are linked to urbanization, often start in childhood and youth, encouraged by
the influence of mass advertising and social pressures. This underscores the importance of targeting children and

in all that aim to prevent heart disease and stroke.

young people programmes
Prevention and control of heart disease and stroke in developing countries represent a challenging task. There are
a number of major barriers to progress, including lack of reliable epidemiological information, inaccessibility of

health care, shortages of trained manpower and resources, and misconceptions about heart disease and stroke among
policy-makers and the public.

However, the good news is that

knowledge about the causes of heart disease and stroke is
growing, and various
countries are gaining experience in translating this knowledge into effective action.

I believe that our efforts to control heart disease and stroke can only succeed if
they are focused at country level.
Current WHO activities in this area are based on the WHO Global Strategy for the Prevention and Control of
Noncommunicable Disease, which was adopted by the World Health Assembly in 2000. Our goals
are to:

provide guidance to countries on policy, legislative and financial measures

that can help prevent cardiovascular disease;

assess and track the magnitude of the cardiovascular disease epidemic and its
social, economic, behavioural and political determinants in developing countries;
reduce cardiovascular risk factors and their determinants and promote
cardiovascular health for all
age groups;

strengthen the health care of people with cardiovascular disease by developing

norms and guidelines
for cost-effective interventions.
 To achieve these goals,
WHO has developed standardized approaches to strengthen national surveillance systems
for
key risk factors. Further, WHO has initiated programmes at country level to scale up health care for those with
established cardiovascular disease and to introduce affordable and innovative approaches for managing cardiovascular
risk factors and cardiovascular disease in low-resource settings.

WHO is also in the process of addressing some of the main risk factors for cardiovascular disease
through global
action, such as the Framework Convention on Tobacco Control and the Global
Strategy on Diet, Physical Activity
and Health. These strategies will help countries in their efforts to
develop and implement policies to reduce the
burden of cardiovascular disease.

We recognize that advocacy, resource mobilization, capacity development, and research are necessary to galvanize
global
action against the causes of cardiovascular disease. WHO
is
working with other UN
agencies, research

nongovernmental organizations, the private sector and civil society to promote these activities. Together
institutions,
we can move the global public health agenda forward to avert unnecessary deaths and suffering due to this eminently
preventable disease.

10
 Preface

"We have the scientific knowledge to create a world

in which most heart disease and stroke could be eliminated."
The Victoria Declaration on Heart Health, 1992

"Change before you have to."

Jack Welch,
former Chairman and Chief Executive Officer of
General Electric, USA (193 5-)

lleart disease and stroke, the main cardiovascular diseases, are truly global epidemics. They deserve the attention
of governments, policy-makers, national and international organizations, committed individuals and families

everywhere.
Heart disease and stroke are no longer diseases of old men in developed countries. They are also diseases of

women, young adults, and even children. They affect the wealthy and the poor. Already they claim more lives in

developing than developed countries. The Asian on the cover is at risk, as are
many children and young adults
girl

throughout the world.

o
The risk factors for heart disease and stroke begin in youth, and most can be prevented or controlled. Yet,
worldwide, most people who have risk factors are either not treated or are inadequately treated. Special attention to

high blood pressure, high blood cholesterol,

tobacco and other major risk factors is crucial.

Cardiovascular diseases are more than just health problems: both the diseases and their underlying causes have
major financial implications for
governments, businesses and individuals. The "globesity" epidemic
is
causing
international concern. The tobacco epidemic is linked to smuggling, big business and politics. If
people are to be
encouraged to take regular physical activity,
commitment is needed from both individuals and society.
The

prevention and control of high blood pressure and high blood cholesterol require action from governments and the
pharmaceutical industry, not just individual patients.

Research achievements in the field of heart disease and stroke have been phenomenal. We know a lot today, but as

Goethe put "knowing not enough, we must apply."

it, is We must apply what we already know, and translate the best

science into practice for the benefit of all, worldwide.

The good news, as stated most eloquently in the Victoria Declaration on Heart Health more than a decade ago, is

that we know what we need to do to eliminate most heart disease and stroke. What is needed now is the

combination of necessary resources and political

will on a
global scale to take effective action.
Now is the time to act

and to change before we have to.

Judith Mackay, Hong Kong SAR, China

George A. Mensah, Atlanta, GA, USA

11
 Acknowledgements
Special thanks go to the following WHO staff for their Burden of Disease, Evidence and Information for
Policy;

support for this project: Catherine Le Gales-Camus, Shanthi Mendis, Coordinator, Cardiovascular
Assistant Director-General, Noncommunicable Diseases Diseases, Noncommunicable Diseases and Mental
and Mental Health; Robert Beaglehole, Director, Health;

Department of Chronic Diseases and Health Promotion; Patricia Mucavele, Technical Officer, Nutrition for

Rafael Bengoa, Director, Health Systems Policy and Health and Development, Noncommunicable Diseases

Operations; and Derek Yach, Representative of the and Mental Health;

Director-General. Mona Nassef, Secretary, Cardiovascular Diseases,
Particular thanks go to the Centers for Disease Noncommunicable Diseases and Mental Health;
Control and Prevention (CDC), United States of Chizuru Nishida, Scientist, Nutrition for Health

America, for their generous financial support of this and Development, Noncommunicable Diseases and
atlas. Mental Health;
For their creativity, artistic talent and innovative Tomoko Ono, Technical Officer, Surveillance and

suggestions
in the
design and cartography of this atlas,
we would like to thank the
Myriad Editions team of
Candida Lacey, Corinne Pearlman, Hay ley Ann and
Isabelle Lewis.
Sincere thanks go to Pat Butler for her editorial input,
and to all colleagues at the World Health Organization:
Dele Abepunde,
O Technical Officer, Cardiovascular
Diseases, Noncommunicable Diseases and Mental Health;
Timothy Armstrong, Technical Officer,
Surveillance and Information for Policy,
Noncommunicable Diseases and Mental Health;
Vishal Arora, Noncommunicable Diseases and
Mental Health, South East Asia Region (SEARO);
Fabienne Besson, Secretary, Management of
Noncommunicable Diseases, Noncommunicable
Information for Policy, Noncommunicable Diseases and
Mental Health;
Leanne Riley, Scientist, School Health and Youth
Health Promotion, Noncommunicable Diseases and
Mental Health;
Gojka Roglic, Technical Officer, Diabetes
Mellitus,Noncommunicable Diseases and Mental
Health;
Jukka Sailas, Scientist, Management Support
Unit, Evidence and Information for Policy,
Noncommunicable Diseases and Mental Health;
Bakuti Shengelia, Medical Officer, Cardiovascular
Diseases, Noncommunicable Diseases and Mental
Health;
Kate Strong, Acting Team Coordinator,
Surveillance and Information for Policy,

Diseases and Mental Health; Noncommunicable Diseases and Mental Health;

Ties Boerma, Director, Measurement and Health Bedirhan Ustun, Coordinator, Classification,
Information Systems, Evidence and Information for Assessment, Surveys and Terminology, Evidence and

Policy; Information for Policy;

Ruth Bonita, Director, Surveillance, Office of Pierre-Michel Virot, Audiovisual and Training
Assistant Director- General, Evidence and Information Team, Information Technology and Telecommunications;
for
Policy;
Amalia Waxman, Project Manager,
Gian Luca Burci, Senior Legal Officer, Office of Noncommunicable Diseases and Mental Health.
the Legal Counsel;

Somnath Chatter] i, Scientist, Classification,
Assessment, Surveys and Terminology, Evidence and
Information for Policy;
Charles Gollmar, Group Leader, School Health
and Youth Health Promotion, Noncommunicable
Diseases and Mental Health;
Carina Marquez, Technical Officer, Surveillance
and Information for Policy, Noncommunicable Diseases
and Mental Health;
Colin Mathers, Scientist, Epidemiology and
Thanks to our colleagues at the National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention (CDC),
United States of America:
Laurie D. Elam-Evans, Deputy Associate Director
for Science, Division of Adult and Community Health;
Wayne H. Giles, Associate Director of Science,
Division of Adult and Community Health;
Kurt J. Greenlund, Senior Epidemiologist,
Science and Communication Unit, Cardiovascular Health

12
Branch, Division of Adult and Community Health; Oxford University, United Kingdom; Hugh Tunstall-

Mary E. Hall, Public Health Analyst, Office of the Pedoe, Cardiovascular Epidemiology Unit, University of
Director; Dundee, United Kingdom (MONICA study).
Virginia
Bales Harris, Director, Division of Adult 19 Organizations Children's Heart Link (USA): Karen
and Community Health; Baumgaertner, International Programs Associate; John
Marsha L. Houston, Health Communication Gushing, International Programs Director. International
Specialist,
Cardiovascular Health Branch, Division of for the Study of Obesity: Neville Rigby, Director
Association

Adult and Communitv Health; of Policy and Public Affairs, International Obesity
Frederick L. Hull, Deputy Chief, Technical TaskForce. International Stroke Society: Julien
Information and Editorial Services Branch, Office of the Bogousslavsky, President-Elect; Frank M. Yatsu,

Director; Treasurer. World Heart Federation: Carola Adler, World

Margaret Malone, Deputy Chief, Cardiovascular Heart Day Manager; Sara Bowen, Website /IT Manager;
Health Branch, Division of Adult and Community Sania Nishtar, Chairman, World Heart Day Committee;

Health; Philip Poole-Wilson, President; Janet Voute, Chief

James S. Marks, Director. Executive Officer.

22 Health education World Heart Federation (as

For their input on particular maps and subjects, we above); Eeva Riitta Vartiainen, Project Manager,
would like to thank the following: International Quit and Win, Finland.

4 Risk factors start in childhood and youth 23 Policies and legislation Omar Shafey, Manager,
Samira Asma, Associate Director, Global Tobacco International Tobacco Surveillance, American Cancer
Control, Office on Smoking and Health, Centers for Society, USA.
Disease Control and Prevention, USA; Jonathan R. 25 The future Rory Collins, Clinical Trial Service

Carapetis, Consultant in Paediatric Infectious Diseases, Unit, Oxford University, United Kingdom; Anthony
Centre for International Child Health, University of Rodgers, Clinical Trials Research Unit, University of
Melbourne, Australia; Gilles Paradis, Division of Auckland, New Zealand.
Preventive Medicine, McGill University Health Center, 26 Chronology Julien Bogousslavsky, President-Elect,
Montreal, Canada; Neville Rigby, Director of Policy and International Stroke Society; Rory Collins, Clinical Trial
Public Affairs, International Obesity TaskForce, Service Unit, Oxford University, United Kingdom; John
International Association for the Study of Obesity; W. Farquhar, Stanford Prevention Research Center,
Charles W. Warren, Distinguished Consultant USA; David Simpson, International Agency on Tobacco
/Demographer, Global Tobacco Control, Office on and Health, London, United Kingdom.

Smoking and Health, Centers for Disease Control and

Prevention, USA. We are also extremely grateful to our families for their

5 Risk factor: blood pressure Yussuf Saloojee, support during the preparation of this atlas.

tobacco control advocate, South Africa.

6 Risk factor: lipids Robert Clarke, Clinical Trial For the use of photographs, we would like to thank the
Service Unit, Oxford University, United Kingdom; Rory following:
Collins, Clinical Trial Service Unit, Oxford University, Front cover Amy, Hong Kong Guy Nowell, Hong
United Kingdom.
o Kong SAR, China, http://www.guynowell.com
7 Risk factor: tobacco Omar Shafey, Manager,
Back cover photographs Cardiology operation,
International Tobacco Surveillance, American Cancer Mauritius WHO /Harry Anenden; man selling
Society, USA. vegetables, IndiaWHO /Pierre Virot; man on bench
8 Risk factor: physical inactivity Krishnan Anand, iStock/Tomaz Levstek; Woman and girl buying
Associate Professor, Centre for Community Medicine, sweets, India WHO/Pierre Virot
All India Institute of Medical Sciences, India. Part 1 Child health examination, Cuba
12 Women: a special case? Sandra Coney, women's WHO /Carlos Gaggero
health advocate, New Zealand. Part 2 Woman cooking, Guatemala WHO/Armando
18 Research Rory Collins, Clinical Trial Service Unit, Waak

13
Part 3
Cardiology operation, USA WHO/Jean 14 Deaths from coronary heart disease
Mohr Cardiology operation, USA WHO/Jean Mohr; heart
Part 4 Youth sport, Germany WHO/Tibor Farkas Hemera Photo-Objects
Part 5 Adolescent group, Peru WHO /Julio Vizcarra 15 Global burden of stroke Pills iStock/ Amanda
Part 6 Man selling vegetables,
India WHO/Pierre Rohde
Virot 16 Deaths from stroke Man on bench iStock/
Tomaz Levstek
I
Types of cardiovascular disease Heart Hemera 17 Economic costs Rice USDA /Ken Hammond;
Photo-Objects potatoes USDA/Ken Hammond
4 Risk factors start in childhood and youth Boy 19 Organizations WHO HQ Geneva

smoking, Seychelles WHO/Harry Anenden; burger WHO/Pierre Virot

Hemera Photo-Objects 20 Prevention: personal choices and actions
6 Risk factor: lipids Arteries American Heart Salad, USA Corinne Pearlman; Amv,
J
HongO KongO '

Association; rice bowl Hemera Photo-Objects Guy Nowell; grapefruit, runner Hemera Photo-
7 Risk factor: tobacco Smoking hand; young people, Objects
Canada WHO/J L Ray; road signs,
USA Corinne 21 Prevention: population and systems
Pearlman approaches Good Heart Food leaflet British

8 Risk factor: physical inactivity TV viewer, biker, Dietetic Association/ Comic Company; hospital
woman with push-chair
wheelchair user, Hemera computer, UK WHO/P Larsen; health examination

Photo-Objects; people on scooter, New Delhi WHO /Julio Vizcarra

Candida Lacey 22 Health Education Posters World Heart
9 Risk factor: obesity Groceries, USA USDA/ Federation
Ken Hammond; apple and pear Woodrow Phoenix/ 23 Policies and legislation Singapore bus WHO/
Comic Company /British Dietetic Association Tibor Farkas; display, gymnasium, Singapore, WHO;
10 Risk factor: diabetes Men playing basketball, fried food, USA (bar chart) Corinne Pearlman; man
Finland WHO /Farkas Tibor smoking, Sri Lanka (bar chart) Garrett Mehl; burger
I 1 Risk factor: socioeconomic status Young boy Hemera Photo-Objects
smoking, China Carol Betson 24 Treatment Man on bike, Finland WHO/Tibor
12 Women: a special case? Hospital patient, Finland Farkas
WHO/Tibor Farkas; smoking woman iStock/ 25 The future Woman, Rwanda WHO/J. L. Ray
Tan Kian Khoon; obese woman iStock/Annette

Birkenfeld; women walking iStock/ Leah- Anne

Thompson; menopausal woman iStock/Joseph Jean Whilst every reasonable effort has been made to contact
Rolland Dube the copyright holders of images used in the atlas, the

13 Global burden of coronary heart disease authors and publisher will gladly receive information
that will enable them to rectify any inadvertent errors in
Cardiology operation, Mauritius WHO/Harry
Anenden subsequent editions.

14
About the authors
Dr Judith Mackay
MBChB, FRCP (Edin), FRCP (Eng)

Dr Judith Mackay is a medical doctor based in Hong

Kong Special Administrative Region, China, and a
Senior Policy Adviser to the World Health Organization.
After an early career as a hospital physician, she became
a health advocate. She is a Fellow of the Royal Colleges
of Physicians of Edinburgh and of London, and an

Honorary Fellow of the Hong Kong College of

Cardiology. Dr Mackay has received many international
awards, including the WHO Commemorative Medal,
the Fries Prize for Improving Health, the Luther Terry

Award for
Outstanding Individual Leadership, the
International
Partnering for World Health Award, and
the Founding International Achievement Award from the

Asia Pacific Association for the Control of Tobacco.

She is the author of The Tobacco Atlas, The State of Health

Atlas and The Penguin Atlas

of Human Sexual Behavior.

Dr George A. Mensah
MD, FACC, FACP, FESC

Dr George Mensah is
acting director, the National
Center for Chronic Disease Prevention and Health
Promotion, and chief of the Cardiovascular Health
Branch at the Centers for Disease Control and
Prevention in Atlanta, Georgia, USA, and clinical

professor of medicine and cardiology at the Medical

College of Georgia. He is a fellow of the American
College of Cardiology, American Heart Association,
and the European Society of Cardiology, and a
foundation fellow of the Ghana College of Physicians
and Surgeons. Recent honours include the
Distinguished
O Research Award of the International

in Blacks, the 25th Bernard

Society of Hypertension
Pimstone Memorial Lecturer at the University of Cape
Town in South Africa, and the National Heart
Foundation of Australia Lecturer at the

50th Anniversary Celebration of the Cardiac

Societies of Australia and New Zealand.

15
16
PART 1

CARDIOVASCULAR DISEASE

"When man is serene, the pulse of the heart flows and connects,

just as pearls are joined together or like a string of

red jade,
then one can talk about a healthy heart."
17
The Yellow Emperor's Canon of Internal Medicine, 2500 BCE
 1
Types of cardiovascular 2 265 824
disease
"All the knowledge I
possess everyone else
can acquire, but my heart is all my own."
Johann Wolfgang von Goethe Deaths from cardiovascular diseases (CVD)
The Sorrows of Young Werther 1774 Number of deaths globally per year
from different types of CVD,
The human heart is
only the size b Y age
/ 1868 339
of a fist, but it is the strongest Highest numbers shown
2002
muscle in the human body.
The heart starts to beat in the
coronary heart disease
uterus long before birth, usually
stroke
by 21 to 28 days after conception.

The average
O heart beats about other cardiovascular diseases

1 00 000 times
daily
or about two
hypertensive heart disease
and a half billion times over a
inflammatory heart disease
70 year lifetime.

With every heartbeat, the heart rheumatic heart disease

pumps blood around the body. It

beats approximately 70 times a

996 183
O this rate can
minute, although
double during exercise or at times
of extreme emotion.
Blood is
pumped out from the

left chambers of the heart. It is

transported through arteries of

ever-decreasing size, finally
reaching the capillaries
in all the

tissues, such as the skin and other

body organs. Having delivered its

oxygen and nutrients and having
collected waste products, blood is
280819

O back to the right

brought O
chambers of the heart through a
104 116
system of ever-enlarging veins. 66542
During the circulation through
the liver, waste products are
0-4 years 5-14 15-29 30-44 45-59 60-69 70-79 80+ years
removed.
This remarkable system is
vulnerable to breakdown and Global deaths from CVD
assault from a variety of factors, millions

of which can be prevented 2002

many inflammatory
total deaths: 16.7 million
and treated. Risk factors will be heart disease
0.4m
explored on pages 24 43.
hypertensive
heart disease
other forms of
0.9m
heart disease
2.4m
 Stroke
Strokes are caused by disruption of the blood supply to the
brain. This may result from either blockage (ischaemic
stroke) or rupture of a blood vessel (haemorrhagic stroke).
atrial fibrillation (a heart
Riskfactors High blood pressure,
Coronary heart disease tobacco use,
rhythm disorder), high blood cholesterol,
Disease of the blood vessels
unhealthy diet, physical inactivity, diabetes,
muscle.
supplving the heart and advancing age.
Major risk factors High
blood pressure,

high blood cholesterol, tobacco use,

unhealthy diet, physical inactivity,

diabetes, advancing age, inherited

(genetic) disposition.
Other risk
factors Poverty, low educational
status, poor mental health (depression),

inflammation and blood clotting disorders.

Aortic aneurysm and
dissection
Rheumatic heart disease
Dilatation and rupture
Damage to the heart muscle and heart
of the aorta.
valves from rheumatic fever, caused by
streptococcal
bacteria. J
^ Riskfactors Advancing age, long-
L standing high
blood pressure,
Mar fan syndrome,
Congenital heart disease
congenital heart disorders,
Malformations of heart structures o
syphilis,
and other
o at birth
existing may be caused bv*
-*

infectious and
genetic
factors or by adverse
inflammatory
exposures during gestation.
disorders.
Examples are holes in the

heart, abnormal valves,

and abnormal heart
chambers.

Riskfactors
Maternal alcohol

use, medicines

(for example
thalidomide, warfarin) used by the expectant Peripheral arterial disease
mother, maternal infections such as rubella, Disease of the arteries
intake of folate),
poor maternal nutrition (low supplying the arms
and legs.
close blood relationship between parents As for
Riskfactors

(consanguinity). coronary heart disease.

Other cardiovascular diseases Deep venous thrombosis (DVT)

Tumours of the heart; vascular tumours of the and pulmonary embolism
brain; disorders of heart muscle Blood clots in the
leg veins,
(cardiomyopathy); heart valve diseases; O and move to
which can dislodge the
disorders of the lining of the heart. heart and lungs.

Riskfactors Surgery, obesity, cancer,

Other factors that can damage of DVT, recent
previous episode
the heart and blood vessel system childbirth, use of oral contraceptive and
Inflammation, drugs, high blood pressure, hormone replacement therapy, long
unhealthy diet, trauma, toxins
and alcohol.
periods of immobility,
for example while travelling, high

levels in the blood.

homocysteine

19
 Rheumatic fever and
rheumatic heart disease
Rheumatic fever usually follows
an untreated beta-haemolytic

streptococcal throat infection in

children. It can affect many parts
of the body, and may result in
rheumatic heart disease, in which
the heart valves are
permanently
damaged, and which may progress
to heart failure, atrial fibrillation,

and embolic stroke.

Nowadays, rheumatic fever

affects children in
mostly
developing countries, especially
where poverty is
widespread. Up
to 1 % of all schoolchildren in

Africa, Asia, the Eastern

Mediterranean region and Latin
America show signs
o of the ST KinS a NEVIS ANTIGUA a BARBUDA
MA
|
I(JRAS
A CAPE VERDE
disease. EL SALVADOI ST VINCENT a GRENADINES (5 ST LJ ^ A SEr
GAMBIA
.i^fGRENADA o O BARBADOS
Of 1 2 million GUINEA-BISSAL
people currently COSTA Rl
01%^* ^H VENEZUELA
'^TRINIDAD a TOBAGO

affected by rheumatic fever and PANAMA^! miYAN;A

SIERRA

rheumatic heart disease, two- COLOMBIA

thirds are children between

5 and 15 years of age. There are
around 300 000 deaths each year,
with two million people requiring

repeated hospitalization and one

million likely to require
surgery
in the next 5 to 20
years.

Early treatment of
streptococcal sore throat can
preclude the development of
rheumatic fever. Regular long-
term penicillin treatment can

prevent rheumatic fever

becoming rheumatic heart
Deaths from rheumatic fever and
disease, and can halt disease *
rheumatic heart disease the Aboriginalin
progression in people whose heart
and non-Aboriginal populations of Australia
valves are already
damaged by the 1979-1996
disease. In
many developing
countries, lack of awareness of Percentage of deaths

these measures, coupled with

Average age at death
shortages of money and
Aboriginal
resources, are important barriers 3
population
to the control of the disease.
non-Aboriginal
67 Y ears
population

20
Deaths from rheumatic heart disease

Number of deaths
/*
PART 2
RISK FACTORS

"He that eats but one dish seldom needs the doctor."
Old Scottish proverb

23
 Risk factors risk factors
Leading
As percentage burden of all diseases
2002
"The gods are and of our pleasant vices high blood pressure
just,
major CVD risk factors
Make instruments to plague us."
tobacco use other risk factors
King Lear, V.iii. 193 William Shakespeare
(1564-1616) high cholesterol

Over 300 risk factors have been

10.2% unsafe sex
associated with coronary heart
5.5% unsafe water, sanitation ft hygiene
disease and stroke. The major
indoor smoke from solid fuels
established risk factors meet three
3.2% zinc deficiency
criteria: a
high prevalence in many iron deficiency

populations; a significant 3.0% vitamin A deficiency High-mortality developing countrie

independent impact on the risk of

coronary heart disease or stroke;

high blood pressure
and their treatment and control
tobacco use
result in reduced risk.
|
high cholesterol
Risk factors for cardiovascular
alcohol
disease are now significant
in all
obesity
populations. In the developed
low fruit ft vegetable intake
countries, at least one-third of all
3.1% underweight
CVD is attributable to five risk
1 .9% indoor smoke from solid fuels
*
factors: tobacco use, alcohol use, Jjsjr
1.8% iron deficiency
high blood pressure, high
1.7% unsafe water, sanitation ft hygiene Low-mortality developing countrie
cholesterol and obesity.

In
developing countries with low
9% high blood pressure
mortality, such as China,
12.2% tobacco use
cardiovascular risk factors also
7.6% high cholesterol
figure high
on the top 10 list.

These populations face a double

9.2% alcohol

burden of risks, grappling with the obesity

low fruit ft vegetable intake

problems of undernutrition and
I

communicable diseases, while also [

physical inactivity

1.8% illicit drug use

contending with the same risks as
0.8% unsafe sex
developed nations.
Even in developing countries 0.7% iron deficiency
eveloped countrie
with high mortality, such as those
in sub-Saharan Africa,
high blood
pressure, high cholesterol, tobacco
Contributory factors M suboptimal systolic
blood pressure
Percentage contribution of selected risk factors
and alcohol use, as well as low more than 115
to coronary heart disease and ischaemic stroke mmHg
vegetable and fruit intake, already 2002 62% high cholesterol

figureamong the top risk factors. 56% ^p low fruit

frui ft vegetable intake
Some major risks are modifiable
physical inactivity
in that
they can be prevented,
treated, and controlled. There are
considerable health benefits at all 31%

ages,
for both men and women, in

stopping smoking, reducing

cholesterol and blood pressure,

eating a healthy diet and increasing

physical activity.

24
ll ll.
coronary heart disease ischaemic stroke
Major modifiable risk factors

High blood pressure Obesity 75% of ely

Major risk for heart attack and the most important Major risk for
coronary heart
disease and diabetes.
ar
risk factor for stroke.

Abnormal blood lipids Unhealthy diets C to

High total cholesterol, LDL-cholesterol and Low fruit and vegetable
triglyceride levels,
and low levels of HDL- intake is estimated to cause
cholesterol increase risk of coronary heart disease about 3 1% of coronary
and ischaemic stroke. heart disease and % of 1 1

Tobacco use stroke worldwide; high saturated fat intake

Increases risks of cardiovascular disease, especially increases the risk of heart disease and stroke through
in
people who started
young, and heavy smokers. its effect on blood lipids
and thrombosis.
Passive smoking
O an additional risk. Diabetes mellitus

Physical inactivity Major risk for

coronary heart disease and stroke.
Increases risk of heart disease and stroke
by 50%.

Other modifiable risk factors

Low socioeconomic status (SES) Alcohol use

Consistent inverse relationship with risk of heart One to two drinks per day may lead to a 30%
disease and stroke. reduction in heart disease, but heavy drinking
Mental ill-health
damages the heart muscle.
Depression is associated with an increased risk of Use of certain medication

coronary heart disease. Some oral contraceptives and hormone

Psychosocial stress replacement therapy increase risk of heart disease.

Chronic life stress, and anxiety
social isolation 1

Lipoprotein(a)
increase the risk of heart disease and stroke. Increases risk of heart attacks especially in

presence of high LDL-cholesterol.

Left ventricular hypertrophy (LVH)

A powerful marker of cardiovascular death.

Non-modifiable risk factors

Advancing age
1
Gender
Most powerful independent risk factor for
Higher rates of coronary heart disease among men
cardiovascular disease; risk of stroke doubles compared with women (premenopausal age); risk

every decade after age 55. of stroke is similar for men and women.
Heredity or family history Ethnicity or race
1

Increased risk if a
first-degree
blood relative has Increased stroke noted for Blacks, some Hispanic
had coronary heart disease or stroke before the Americans, Chinese, and Japanese populations.

age of 55 years (for a male relative) or 65 years Increased cardiovascular disease deaths noted for

(for a female relative). South Asians and American Blacks in

comparison
with Whites.

"Novel" risk factors

Excess homocysteine in blood Abnormal blood coagulation

High levels may be associated with an increase in Elevated blood levels of fibrinogen and other
cardiovascular risk. markers of blood clotting increase the risk of

Inflammation cardiovascular complications.

Several inflammatory markers are associated with

O elevated
increased cardiovascular risk, e.g.
C-reactive protein (CRP).
25
 Risk factors start in
childhood and youth
"Encased in fat in youth, encased in a
coffin in middle age."
Both sexes aged 6 to 1 1
years Both sexes aged 12 to 19 years
Ancient Chinese proverb
6.5/o 5.0%
Although cardiovascular diseases 1 0.5%
typically
occur middle age or
in

later, risk factors are determined

to a great extent by behaviours

learned in childhood and

continued into adulthood, such as

habits and smoking. Overweight trends in the USA

dietary
Percentage of young people
Throughout the world, these
who are overweight
risks are to appear earlier.
starting 7976-2000
Physical activity decreases
in adolescence,
markedly
particularly
in
girls. Obesity has
increased substantially, not only
in
Europe and North America,
but also in traditionally slender

populations such as the Chinese

and Japanese. Type 2 diabetes was

previously rare in children, but is

in adolescents in, for
increasing
example, North America, Japan
and Thailand.
Markers of CVD can be seen in

young children. Post-mortems of

Overweight youth
children who died in accidents Percentage of 15-year-olds
have found fatty
streaks and who are overweight

fibrous plaques in the coronary 7997-7998

selected countries
arteries. These early lesions of 5.1%
atherosclerosis were most W males
Belgium
(Flemish)
frequently found in children females
^0 zech
whose risk factors included
public
Denmark
smoking, elevated plasma lipids,
high blood pressure and obesity.
Programmes to address

childhood and youth risk factors

are mostly confined to developed

countries, but urgent action is 10.8%

required worldwide. Families,

schools, communities, health

professionals, public health

officials and policy-makers all

need to promote healthy lifestyles

in children and
young people.
Unless the spread of risk factors is

stemmed, the world faces an

epidemic of CVD.
26
 o-o
RUS5IAN FEDERATION

"' ^
UNISIA LEBANON' IS1 . RE p,

WEST BANk"*" JORDAN

LIBYAN AND GAZA

V
CUBA ARAB
MEXICO
HK^^^B
JAMAICA \ ,
JAMAHIRIYA EGYPT

BELIZE
GUATEMALA 'r.^Sft NEVIS
ELSAIVAOOR \DURAS ST VINCENT ft
_ . -SUTJCIA

GRENADA nuKMO TOBAGO

COSTA RICA ft

PANAMA VENEZUELA GUYANA

COLOMBl
F 4

Early starters

Percentage of students, primarily aged 13 to 15 years,

using tobacco
7999-2003

45% and above

300/0-44.9%

15%-29.9%

below 1 5%

no data

TUNISIA LEBANON- ISl.REP

MOROCCO j- IRAN
WEST BANK JORDAN
AND GAZA KUWAIT

MEXICO
CU6 *
BAHAMAS

^ 7
G >;

ANT'luA ftB. !.B U DA

LIBYAN
ARAB
JAMAHIRIYA EOYPI
BAHRAIN^
^ ^ l
.
^
^JAMAICA TANIA
MAURITl I- MYANMAR ^S
GUATEMALA
EL SALVADOR
x
\
hONBURAS
ST POTS
S
fl NEVIS v
^unNTSfRRAI |UK1 '

^ X%v
NIGER OO -<
^J E^-
ST LUCIA
SENEGAL ^J
COSTARICA GRENADA IRINIDAD ft TOBAGO VIETNAM
% NIGERIA CAMBODIA PHILIPPINES
PANAMA VENEZUELA GUYANA
SRI LANKA PALflu ,
SL'RINAME .
COLOMBIA T

^
ECUADOR

N D N E S

Girls ZIMBABWE

SWAZILAND
SOUTH

<>
oooo
URUGUAY
AFRICA LESOTHO

ARGENTINA

27
 Risk factor: blood pressure
"There are six flavours and, of them all,
igh blood pressure in the USA
salt is the chief."
Percentage of people aged 20 to 74 years
Hindu proverb
with blood pressure of 140/90 mmHg or above,
or taking anti-hypertensive medicine,
Black non-Hispanic female
High blood pressure Black non-Hispanic male age-adjusted
976-2000
(hypertension) is one of the most
/

White non-Hispanic male

important preventable causes of
premature death worldwide.
Even a blood pressure at the top
end of the normal range increases White non-Hispanic female
risk.
High blood pressure is
defined as a systolic blood
Mexican male 125.6
pressure (SBP) above 140 mmHg Mexican female 22.
and/or a diastolic blood pressure

(DBF) above 90 mmHg. 1988-1994 1999-2000

In most countries,
up to 30% of
adults suffer from high
O blood Blood pressure changes with age in the Gambia
pressure and a further 50% to
7996-7997
60% would be in better health if

they reduced their blood

pressure, by increasing physical

maintaining an ideal body

activity,

weight and eating more fruits and

vegetables
O .

In
people aged up to SO years,
both DBF and SBP are associated \ \
with cardiovascular risk; above 16-24 26-35 36-45 46-55 56-65 66-75 76-100
this
age,
SBP is a far more years years years years years years years

important predictor. Blood

pressure usually rises with age,
except where salt intake is low,
Blood pressure in India High blood pressure
physical activity high, and obesity
Average systolic blood pressure by years of education
largely absent. in urban men HI I
in South Africa
Most natural foods contain salt, aged 40 to 49 years Percentage of people
7942-7997
but processed food may be high in aged 15 and above
salt; in addition, individuals
mmHg with blood pressure
may
add salt for taste. salt higher than
Dietary
increases blood pressure in most
160/95 mmHg
7998
people with hypertension, and in female
about a quarter of those with
normal blood pressure, especially
with increasing age. A high intake
of salt independently increases the
risk of CVD in overweight
persons.
In addition to
lifestyle changes,
effective medication is available

high blood pressure.

for control of

28
 Average systolic blood pressure of people
: aged 30 years and above
estimated to 2005

mmHg
data from urban populations only
 Risk factor: lipids

o levels of LDL-cholesterol,
High
and other abnormal lipids (fats),
are risk factors for cardiovascular

disease. Cholesterol is a soft,

waxy substance found among the

lipids
in the bloodstream and in
all the body's cells. It is needed to
form cell membranes and
hormones, and for other bodily
functions.

The body can make cholesterol,

or it can obtain it from food,

especially
animal products such as

meats, poultry, fish, eggs, and

dairy products. Certain saturated

vegetable fats and oils, including

coconut fat and palm oil, are

cholesterol -free but cause an

increase in blood cholesterol.

Some foods that do not contain

animal products may contain

trans-fats, which also cause the

body to make more cholesterol.

Fruit, vegetables and cereals do

not contain cholesterol .

Cholesterol is
transported
around the body in two kinds of

lipoproteins: low-density

lipoprotein, or LDL, and high-

density lipoprotein, or HDL.

A high level of LDL can lead to
clogging of the arteries,
increasing the risk of heart attack
and ischaemic stroke, while HDL
reduces the risk of coronary heart
disease and stroke.

The female sex hormone Current recommended lipid levels

estrogen tends to raise HDL-

European guideline US guideline
cholesterol levels, which may
Total cholesterol less than 5.0 mmol/l less than 240 mg/dl (6.2 mmol/l)
help explain why premenopausal
women are relatively protected
LDL-cholesterol less than 3.0 mmol/l less than 160 mg/dl (3.8 mmol/l)
from developing coronary heart
disease.
HDL-cholesterol 1.0 mmol/l or more in males 40 mg/dl (1 mmol/l) or more
1.2 mmol/l or more in females

Triglycerides (fasting) less than 1.7 mmol/l less than 200 mg/dl (2.3 mmol,

30
 Cholesterol

Average cholesterol levels in women aged 30 and above

mmol/litre
estimated to 2005
# data from urban populations only

6.0 and above Average cholesterol levels

in men more than 0.4 mmol/litre

5.5-5.99 rf higher than in women

5.0-5.49

Average cholesterol levels

3.0-4.99

no data
9 in women more than 0.4 mmol/litre

higher than in men

Fatty deposits along the inside

of artery walls lead to
atherosclerosis and

narrowing of the arteries.

Trends in cholesterol levels in Beijing, China

Average total cholesterol in people aged 25 to 64 years 5 25

7984-7999
mmol/l
'1999

1996
1996

1993
1984
31
 Risk factor: tobacco

"From a short pleasure can come a long

repentance." Cardiovascular risks of smoking

French proverb

Percentage increase in risk

The public may believe that the 100% 300% more than 300% 400%
risk from is increase in risk increase in risk increase in risk increase in risk
major cigarettes lung
cancer, but far more smokers
develop cardiovascular disease
mainly heart attacks and stroke. In
1940, a link was identified
between cigarette
use and

coronary heart disease, and there

now stroke; coronary death from peripheral
Aim
''

aortic
is
huge body of scientific
a
heart disease; arterial
undiagnosed aneurysm
literature linking tobacco with
impotence coronary heart disease
CVD. The risks are much higher disease

in
people who started smoking
before the age of 16. Tobacco
Cardiovascular risks of passive smoking
use, other than smoking, and

passive smoking are also

Adults
implicated CVD risks.
as
Harms, clogs,
and weakens arteries
Smoking promotes CVD Heart attack, angina, stroke
through several mechanisms. It
damages the endothelium lining Children
of the blood vessels, increases
Reduces amount of oxygen the blood can carry
cholesterol plaques (fatty deposits
arteries
in the arteries), increases
Damages
clotting,
Earlv-onset atherosclerosis
raises LDL-cholesterol levels and
Sudden infant death svndrome (cot death)
lowers HDL, and promotes
coronary artery spasm Nicotine .

accelerates the heart rate and

raises blood pressure.

oA
gene has been discovered that Smokers don't know the risks of heart attack
increases smokers' risk of
Percentage of smokers
developing coronary heart disease
in the USA
by up to four times. Around a who believe they have

quarter of the population carries higher-than-average

one or more copies of this gene. heart attack -,
i/ftThf
Women smokers are at 1399

particular risk, with a higher

risk

of heart attack than male

smokers. Women who smoke
only three to five cigarettes a day
double their risk of heart attack,
while men who smoke six to nine
39%
heavy Y4
cigarettes
a
day double their risk.
smokers
(40 or
more
per day)

32
 ft
"S,
1 <2> '*'.

*$*

DOMINICAN

~^W~ r ~*
MAURITANIA **Al

"'"T VINCENT E, ^ST LUCIA. SENEG*

GRENABIS-0 BARBADOS.
COSTA RICA ,,*
PANAMA*

KIIAIKM

UWJGUAv
Men
Smoking prevalence

Percentage of people aged 18 years and above

who smoke
2003 or latest available data
* data from urban populations only

IB 6Qo/o and above

B 45o/o-59.9%

300/0-44.9%

LATVIA
LITHUANIA
-BELARUS
Y POLAND

"*'" EP
JAMAICA
EMALA
STVINCENTE,
GRENADINES^
^O LUCIA.

B^BOS,
COST* RI " VtNBUBA. CAMBODIA PHIUPP.NB

URUd

AB6ENTINA

Women
 8 Risk factor:

"Take a meals and you won't

stroll after
physical inactivity
have to go to the medicine shop." Sitting
Ancient Chinese proverb Time spent seated each week,
people aged 18 years and above
Industrialization, urbanization and 2000
mechanized transport have selected countries
j/nours
35 hou|
reduced physical activity, even in
U^! S
29 hours
developing countries, so that
currently more than 60% of the
global population are not
sufficiently active.

Physical exercise is linked to

longevity, independently
of
Netherlands United
genetic factors. Physical activity, Finland, Italy Spain
France Kingdom
even at an older age.
O can '

significantly
reduce the risk of

coronary heart disease, diabetes,

Physical activity
high blood pressure, and obesity,
help reduce stress, anxiety and The following activities have similar benefits to health:

depression, and improve lipid

Washing and waxing a car for 45-60 minutes
profile.
It also reduces the risks of

colon cancer, breast cancer and Washing windows or floors for 45-60 minutes
ischaemic stroke.
Playing volleyball for 45 minutes
Doing more than 1 50 minutes
of moderate physical activity or Wheeling self in wheelchair for 30-40 minutes
60 minutes of vigorous physical
Bicycling 8 km in 30 minutes
a week whether at
activity
work, in the home, or elsewhere Pushing a pushchair 2.5 km in 30 minutes
can reduce the risk of coronary
Walking 3 km in 30 minutes
heart disease by approximately
30%. Swimming laps for 20 minutes
Despite documented evidence
Playing basketball for 15-20 minutes
of the benefit of physical activity
in
preventing and
treating
cardiovascular and other chronic

diseases, more than a quarter of a

million individuals die each year

in the United States because of a
"lack of Physical inactivity by social class in India
regular physical exercise".
Percentage of time spent seated, at work or in spare time,
Only 8% of the world's
by people aged 25 years and above in two Indian villages 82o/o

population currently owns a car. 7993-7995

69%
Between 1980 and 1998, the

global fleet of cars, trucks and

buses grew by 80%, with a third
37%
of the increase in
taking place
27%
developing countries.

lowest
6%
CDCD
6%

next lowest
D
next highest highest
34
 INLAND

UNITED
SWEDEN
^u.
KINGDOM
omuHK
JIIH

BELGIUM GERMANY
-

LUXEMBOURG
FRANCE
^^
^a
MflVAKiA

CROATI

ITAIY
SPAIN
r
ff^H
PORTUGAL GREECE

BRAZIL

MfURUGUAY
MM|^^B|j^HH|^H|^HHjj^^^^^|^^HHHHBMB|
Physical activity levels
^
Energy expenditure per week in work, leisure and transport
MET-mins
2002-2003
1 MET is the amount of energy expended while sitting quietly at rest

H 6000 and above below 1300 ^

HI 3500-5999 no data

750
Singapore keeps moving
Percentage participationin any form of sport for
at least20 minutes, on 3 or more days a week, by age
1998

female
^y
 Risk factor: obesity
"Eat less at dinner and you will live to
Food consumption
ninety-nine."
Ancient Chinese proverb Trends in food consumption in

developing and industrialized countries

7964- 7999, 2075 projected
girth and
Belt size, abdominal O
kcal per capita per day
waist-to-hip ratio are useful
indicators of
obesity.
The Body
Industrialized 29_4Z
Mass Index (BMI), a measure of
countries
in relation to is
weight height,

commonly used for

classifying

overweight and obesity.

The risks of cardiovascular

disease and type 2 diabetes tend to

Developing 2 Q54
increase on a continuum with countries

increasing BMI, but for practical 1964-66 1974-76 1984-86 1997-99 2015

purposes a person with a BMI of

over 25 is considered overweight,
o '

while someone with a BMI of over

30 is obese. But one size does not
fit all. In women, a BMI as low as

2 1
may be associated with the

greatest protection from coronary

"If you and three
heart disease death. The BMI for friends together
observed risk in different Asian weigh more than
360kg, you get a
populations varies from 22
free bottle of
2
to 25 kg/m .

whisky."
of food, changes in
Availability Ichub Club.
the kind of food eaten, and fat-themed
karaoke bar in
decreased exercise are presenting
Bangkok,
humanity with one of its greatest Thailand,

challenges.
Low fruit and 2002

vegetable intake accounts for about

20% of CVD worldwide. Obese
smokers live 1 4 fewer years than
Apple shape at higher risk of CVD than pear shape
nonsmokers of normal weight.
Waist-to-hip ratio of 0.91 and above is associated with nearly
More than 60% of adults in the
threefold increased risk of coronary heart disease.
USA are overweight or obese.
Increased CVD risk if: Men Women
Triple-width coffins, capable of
holding a 300 kg (700 Ib) body, are Waist to hip ratio
in
increasing demand. Worldwide,
Waist measurement
airlines are
O to recalculate
having
their
passenger "payload" weight.
There are 70 million overweight

people in China. South Pacific

populations used to be physically

region now
active and slim, but the

has some of the world's

highest
rates of
obesity.
 JAfAN
REP
KOREA

COOK
ISLANDS
THAILAND
PHILIPPINES

NIGERIA

GHANA .CAMEROON

N D N E S I A

MALAWI

ZIMBABWE

Men
Body Mass Index (BMI)
HiHHH
Average BMI of people aged 1 5 years and above
estimated to 2005
2
kg/m
* data from urban populations only

18-22.9

no data

Women
 10 Risk factor: diabetes
"The urine of diabetics is wonderfully
Lifestyle changes can be
sweet as if imbued with honey or sugar."
more effective than drugs
Thomas Willis (1621-1675), physician to GREENLAND

King Charles II, England

in preventing type 2 (DK)

diabetes.

Diabetes is a risk factor for

coronary heart disease and stroke,

and is the most common cause of

amputation that is not the result

CANADA
of an accident.
Insulin is a hormone produced
by the pancreas and used by the
body to regulate glucose (sugar).
Diabetes occurs when the body
does not produce enough insulin,
or cannot use it properly, leading
to too much sugar in the blood.
Symptoms include thirst,
DOMINICAN
excessive urination, tiredness, and JAMAICA
HAITI
BELIZE
r-. ANTIGUA ft BARBUDA
GUATEMALA ST Kins NEVIS
unexplained weight loss. HONDURAS Et I

O
O DOMINICA CAPE VERDE
SENEGAL
EL SALVADOR ST VINCENT ft GRENADINES O$T LUCIA
There are two main types of NICARAGUA
GRENADA 6 O BARBADOS
GAMBIA

COSTA RICA ^ TRINIDAD TOBAGO Et

GUINEA-BISSAU
diabetes. Type 1
diabetes, in GUI
VENEZUELA GUYANA SIERRA LEONE
which the pancreas stops making
COLOMBIA
insulin, accounts for 10% to 15%
of cases.The majority of people
with diabetes have type 2 disease,
in which insulin is
produced in

smaller amounts than needed, or

is not properly effective. This
form is
preventable, because it is

related to physical inactivity,

excess calorie intake and obesity.

People with type 1 diabetes need

insulin injections to lower blood

sugar,
but many people with
type 2 do not.
At least half of all people with
diabetes are unaware of their

condition. Diabetes is more

in
prevalent developed countries,
but modernization and lifestyle

changes are likely to result in a

future epidemic of diabetes in

developing countries.

38
 Prevalence of diabetes

D
DM

NETH

BELGIUM

I
 11 Risk factor:
socioeconomic status
"Wealth is both an enemy and a friend."
Nepalese proverb
Prevalence of CVD risk factors

by education in Canada
In
developing countries, coronary
heart disease has historically been Percentage of people aged 1 8 to 74 years

more common in the more with high levels of physical inactivity

and high cholesterol, by educational level,
educated and higher
age standardized 1986-1992
socioeconomic groups, but this is

beginning to change. In industrial men

countries, such as Canada, the secondary school not complete'
f women
United Kingdom, and the United
physical inactivity
47%
States, there is a
widening social

class difference in the

opposite high cholesterol 46%
direction.
secondary school completed
Studies in developed countries
37%
suggest that low income is
physical inactivity

associated with a higher

o incidence high cholesterol 45%
of coronary heart disease, and
with higher mortality after a heart university degree obtained

attack. The prevalence of risk physical inactivity 37%

factors for heart disease, such as
high cholesterol 38%
high blood pressure, smoking and
diabetes, is also higher. The use of
medications is lower, especially of The CVD mortality gap in the USA
lipid-lowering agents and ACE
Percentage increased CVD mortality
inhibitors, as well as other
of lowest socioeconomic (SE) group
94%
treatments, such as cardiac over highest SE group,
catheterization. in people aged 25 to 64 years
The pathways by which 7969-7998

socioeconomic status might affect 49% 79%

cardiovascular disease include:

lifestyle
and behaviour patterns; 30%
ease of access to health care; and
1969-1970 1997-1998
chronic stress.

Prevalence of high blood pressure

by income in Trinidad and Tobago

Percentage of women aged 24 to 85 years with blood pressure

of 140/90 mmHg or above, or currently treated

2007

1%

~
less

US$134
than US$
134-267
III
US$
268-533
US$ US$ more than
534-1067 1068-2133 US$2133

monthly household income

I Educational level and
obesity in Italy

Percentage increased risk of obesity in people

aged 35 to 74 years, 380%
in comparison
with university graduates
7998

2200/0

250%
upper
secondary
education
I
60% no

diploma qualification

In China, years of education are more important than occupation, income or

marital status in relation to cardiovascular risk factors, especially cigarette

smoking.

Income and obesity in Saudi Arabia

Percentage of people aged 20 years and above

with Body Mass Index
of more than 30 kg/m 2
7990-7993

Smoking and occupation in Uganda

Percentage of women aged 1 5 to 54 years and men aged 1 5 to 59 years
who currently smoke daily by category of work
2000-2007

income less than US$ US$ more than

US$533 533-1066 1067-2133 US$2134
34% 33%
29%

14%
** 3%
^% ^% 10/Q 0%
unskilled skilled sales
Prevalence of diabetes
agriculture, professional, unemployed
self-employed manual manual technical, (previous by income in India
managerial, 12 months)
clerical Percentage of people
22%
aged 20 years and above

* Smoking
Smo by years of education in South Africa
with diabetes,

by income level

2000
Percentage of people aged 15 years and above who currently smoke daily
7998

;
f men

r women

45o/o 45o/o
39% less than more than
35% 33% 112-223
US$111 US$223
25o/o

100/ jl
8% 9% 8%
no up to 6-7 8-11 12 more than
education 5 years years years years 12 years
41
 12 Women: a special case?

Widespread misconceptions
persist about
heart disease, often

thought to be primarily a disease

of middle-aged men. In reality,
cardiovascular disease affects as

many women as men, albeit at an

older age. Many women still
believe that they are more at risk

from cancer than from heart

disease.

Risk factors for CVD are similar

for men and women, but tobacco

use is more dangerous in women. Risk factors
In addition,
high blood
are an important
triglycerides Modifiable risks - risk or prevalence is higher in women than men
cause of atherosclerosis in young

women, but not in young men. Tobacco use (higher risk)

The menopause has no direct
High triglyceride levels (higher risk)

effect, but hormone replacement Diabetes (more prevalent)

therapy increases the risk of Obesity (more prevalent)
CVD.
Depression (more prevalent)
Heart disease is under-detected
inwomen, particularly younger
women. In developed countries, Modifiable risks - risk is similar in men and women
women are less likely to be

referred to a heart specialist, to High blood pressure

be hospitalized, to be prescribed High total cholesterol
medicine or invasive treatment, Low HDL-cholesterol
or to be referred for exercise Combined hyperlipidaemia
or echocardiography.
testing Unhealthy diet
Women are more likely to enter Physical inactivity
the medical system with the Stress

diagnosis of a second heart

attack.

After a first stroke, women are

in and Risks for women only

kept hospital longer,
remain more disabled than men
Oral contraceptive use
receiving similar care. More
research is needed to improve our
Hormone replacement therapy
Polycystic ovary syndrome
understanding of the differences
Risk of heart attack highest early in each menstrual cycle
in
responses to treatment in men
and women.
In the interim, however,
adherence to the published
Non-modifiable risks for men and women

guidelines for the prevention and

control of heart disease and stroke
Advancing age
Gender
seems prudent.
Heredity
Ethnicity/race

42
Smoking
Percentage increase in risk of heart attack
in people who smoke in Denmark
7976-7993

60%

ex-smokers light smokers moderate smokers heavy smokers

Women who smoke are at

(1-Hg/day) (15-24 g/day) (>24g/day) higher risk of heart attack

than men who smoke.

No time to walk
Percentage of women in the United Kingdom

aged 15 years and above who do not exercise more Walking re

because of lack of time or motivation coronary heart disease

2003 Percentage reduction in risk of

40% coronary heart disease by non-

vigorous walking in women
45 and above in the USA
7992-7999

no time not motivated

to exercise to exercise

111%
Hormone
replacement therapy
Percentage increase
in risk of CVD
in healthy women
usingHRT in the USA
7997-2000 1-59 1-1.5 2 or more
minutes hours hours
a week a week a week

41%
29%
22%

lul
coronary
heart
stroke deep
venous
disease thrombosis 43
PART 3

THE BURDEN

"You don't get to choose how you're going to die, or when.

You can only decide how you're going to live now."
Joan Baez, folk singer and activist, USA (1941-)
45
 13 Global burden of coronary
heart disease
"Misfortunes always come in by a door
that has been left open for them."
Czechoslovakian proverb

life
Disability-adjusted years
(DALYs) can be thought of as
lost

"healthy years of life lost". They

indicate the total burden of a
disease, as opposed to simply the
resulting deaths.
Cardiovascular disease is
Coronary heart disease burden is projected to
responsible for 10% of DALYs
rise from around 47 million DALYs globally in
lost in low- and middle-income 1990 to 82 million DALYs in 2020.
countries, and 18% in high-
O USA
income countries.
A heart attack occurs when the

blood vessels supplying the heart

muscle become blocked, starving O REP
JAMAICA
BELIZE
itof oxygen, leading to the heart HONDURAS
ST KITTS ft NEVIS 0O ANTIGUA ft BARBUDA

ST VINCENT GRENADINES
muscle's failure or death. Heart EL SALVADOR ft

NICARAGUA 6RENADA .3 O BARBADOS

attack has the same risk factors as COSTA RICA '-' TRINIDAD ft TOBAGO
GUINEA-BISSAU
GUINI
VENEZUELA
CVD in general.
O Cold weather. PANAMA GUYANA SIERRA LEC

exercise, or strong emotion can

precipitate a heart attack.

Coronary heart disease is

decreasing in many developed

countries, but is increasing in

developing and transitional

countries, partly as a result of

increasing longevity,
urbanization, and lifestyle

changes.
Risk of heart attack can

change when people migrate.

Japan has a low rate of
coronary heart disease, but sase burden in men
after moving to the USA, Percentage of DALYs lost
O HIV/AIDS coronary due to top ten diseases
Japanese people have been 7.4% heart disease
n men aged 15 years and above
found to have a gradually 6.8%
2002
O risk. This
increasing
chronic
eventually approaches that alcohol
tuberculosis obstructive
of people born in the USA. use
4.2% pulmonary hearing
disorders loss
disease .

3.1% adult
2.7%

46
 Healthy years of life lost to coronary heart disc
ElANP
MNLAND DALYs lost per 1000 population, age-standardized
SWEDEN
estimates for 2002
NORWAY

ESTONIA Disability-adjusted life years combine years of potential life lost due

UNITtD LATVIA
to premature death with years of productive life lost due to disability
KINGDOM
DENMARK LITHUANIA

3 NIGERIA
|||
*
2 CENTRAL AFRICAN
OIRt
REPUBLIC
EQUATORIAL
CAMEROON
GUINEA UGANDA
KENYA
GABON
DEM-REP. RWANDA
^PRINC^E
CONGO BURUMO,
UNITED REP
TANZANIA

COMOROS
ANGOLA
MALAWI
ZAMBIA

ZIMBABWE MAURITIUS
NAM ' BIA
BOTSWANA
MOZAMBIQUE

SWAZILAND AUSTRALIA
SOUTH
LESOTHO
AFRICA

unipolar
depressive
disorders -4-4

HIV/AIDS Disease burden in women

7.2% Percentage of DALYs lostdue to top ten diseases
coronary
heart
in women aged 15 years and above
disease 2002
stroke
5.3% 5.2%
chronic
obstructive

cataracts
h " ring pulmonary
3 ' 1% d S C tuberculosis osteo- diabetes
->8%
1.8% o
2.7% 26% .

arthrit s mdijtus

47
 14 Deaths from coronary
heart disease
"People live with their own idiosyncrasies
and die of their own illnesses."
Vietnamese proverb

Civilization kills. Since 1990,

more people have died from

coronary heart disease than from

any other cause. Unlike stroke,

coronary heart disease is a
comparative newcomer on the
world stage. Variations in death
Despite implements in survival
rates are marked: they are lower
1 in 4 men^Bi 1 in 3 women still die withir
in
populations with short life of a heart attack.
recogn^B first

expectancy.
Heart disease mortality rates are
also affected
by differences
between countries in the major
risk factors,
especially blood
CAPE

pressure, blood cholesterol, VERDE MAfl

smoking, physical activity

and
diet. While genetic factors
play a GUINEA-BISSAUj
OUINfl

part, 80% to 90%

of people dying
from coronary heart disease have
one or more major risk factors
that are influenced
by lifestyle.
Death rates from coronary heart
disease have decreased in North

America and many western

European countries. This decline

has been due to improved
prevention, diagnosis, and
treatment, in particular reduced

cigarette smoking among adults,

and lower average levels of blood

pressure and blood cholesterol. It

82% of the future Deaths from
is
expected that
increase in coronary heart disease coronary heart disease
mortality will occur in developing compared with other causes
Number of deaths of people
countries.
aged 15 to 59 years,
Of all coronary heart disease and 60 years and over
patients who die within 28 days 2002
after the onset of thousands
symptoms,
about two-thirds die before

reaching hospital. This highlights

not only the need for early

recognition of the warning signs

of a heart attack, but also the
need for prevention.

48 15-59 years 60 years and above

 Deaths from coronary heart disease

Number of deaths from coronary heart disease

2002

500 000 and above 1000-9999 T P 3

highest number of
100000-499999 deaths from

coronary heart
10 000-99 999
disease

increase in death rates

Croatia

Kazakhstan

Belarus

Ukraine

Romania

Japan -10%
Hungary -2% ||+2% Change of heart
Percentage change in
-11% -15% Greece
coronary heart disease death rates,
-19% l^HB^l Portugal in people aged 35 to 74 years
USA 7988-7998
selected countries
Netherlands

-40% -Mi Sweden women

Luxembourg men
Australia

-49% Denmark
decrease in death rates 49
 15 Global burden of stroke
"I waked and sat up.. .when I felt a

confusion and indistinctness in my head

which lasted, I
suppose about half a
minute. Soon after I
perceived that had I

suffered a paralytick stroke, and that my

Speech was taken from me."
Samuel Johnson, England, 1783

Stroke is the brain equivalent of a

heart attack. Blood must flow to

CANADA
and through
o the brain for it to
function. If its flow is obstructed,
The increased of stroke from taking
risk

by a blood clot moving to the

contraceptive substantially reduced by
pills is

brain, orby narrowing or bursting using the modern, low-dose pill.

of blood vessels, the brain loses its

energy supply, causing damage to

tissues leading to stroke .

1 5 million people
Annually,
worldwide suffer a stroke. Of
these, 5 million die and another MAURIlB

5 million are left

CAPE VERDE O fl
permanently EL SALVADOR ST VINCENT ft GRENADINES GAMBIA 2|
NICARAGUA J BARBADOS
disabled, placing a burden on COSTA RICA
GRENADA^
T RINIDAD a TOBAGO
GUINEA-BISSAU' ^
GUI
UINI

family and community.

Stroke is PANAMA VENEZUELA
SIERRA LEO

uncommon in people under COLOMBIA

40 years;
when it does occur, the

main cause is
high blood pressure.
Stroke also occurs in about 8% of
children with sickle cell disease.
The major risk factors for stroke

are similar to those for coronary

heart disease, with high blood

pressure and tobacco use the most

significant
modifiable risks. Atrial

fibrillation, heart failure and heart

attack are other important risk

factors.

The incidence of stroke is

in
declining many developed
countries, largely as a result of

o blood
better control of high

pressure, and reduced levels of

O However, the absolute

smoking.
number of strokes continues to
increase because of the ageing

population.

50
 Healthy years of life lost to strol

DALYs lost per 1000 population, age-standardized

2002
Disability-adjusted life years combine years of potential life lost due
to premature death with years of productive life lost due to disability

NETH.

BELGIUM GERMANY

IMK.TDIA HUNGARY MOiDOV

AUSTRIA ROMANIA
SWITZ. SLOVtNIA BOSNIA ft
HERZEGOVINA
^Kff
ChVAtt* I SERBIA h _...-.
MONTENeSRO BUlGAI1
ANDORRA' MONACO lwy

"" CH'
"
1
NIGERIA
I
I^H CENTRAL AFRICAN

EROON
REPUBLIC
^P^^^pq
OUATORIAL'V
GUINEA

' JKBfl i
NYA

as-
:

,
 16 Deaths from stroke

O risk of death.
Stroke carries a high
Survivors can experience loss of
vision and /or speech,
paralysis,
and confusion. Historically called

"apoplexy", "stroke" is so called

because of the way it strikes

people down.
Previous stroke significantly
increases risk of further episodes.

Certain racial, ethnic and Stroke is the second leading cause of death
socioeconomic groups are also at above the age of 60 years, and the fifth leadir

The most cause in people aged 15 to 59 years old.

greater risk of stroke.
important modifiable cause of ...
strokeis
high blood pressure; for
every ten people who die of
'.>

stroke, four could have been

saved if their blood pressure had

%
DOMINICAN
JAM
*'^ Hafliir
been regulated. Among those MAURI
GUATEI
ST KITTS ft NEVIS C ANTIGUA
, Et BARBUDA
e
CAPE VERDE .

aged under 65, two-fifths of EL SALVADOR^- SENM

GAMB
:NADAO O BARBADOS
deaths from stroke are linked to * TRINIDAD TOBAGO
it
GUINEA-BISSA
GUINl

smoking. Other modifiable risk SIERRA LEO

factors include
unhealthy diet,
underlying heart
salt intake,
high
disease, diabetes and high blood

lipids.
The risk of death
depends on the
type of stroke. Transient
ischaemic attack or TIA where
symptoms resolve in less than

24 hours has the best outcome,

followed by stroke caused by

o of the
carotid stenosis (narrowing
v

artery in the neck that supplies

blood to the brain). Blockage of
an artery is more
dangerous, with
rupture of a cerebral blood vessel 420%
themost dangerous of all. Predictors of death
Even where advanced from stroke in Italy

Percentage increased risk of death from stroke

technology and facilities are
in people aged 65 years and above
available, 60% of those who
2007
suffer a stroke die or become
dependent. Given these dismal 140%
statistics and the 84%
high cost of 83%
treatment of stroke, high priority
60%
38%
should be accorded to preventive

strategies. previous atrial high impaired cigarette coronary

stroke fibrillation blood glucose smoking heart

pressure tolerance disease

(systolic
52 >163 mmHg)
 Number of deaths from stroke Top 3
2002 highest number of
deaths from stroke
200 000 and above 1000-9999

100000-199999 below 1000

10 000-99 999 no data

100/0
stroke
5.5 million

27%
other causes
Stroke compared 15.6 million heart disea
with other causes of death 7.2 milli

Percentages and numbers of deaths

worldwide from stroke and Total
other leading causes deaths
2002 57 million
12%
malaria cancer
1.2 million 1 million

3%
tuberculosis
1.6 million
30/0 respiratory
diarrhoeal diseases infections
1.8 million 3.7 million
40/0
5%
HIV/AIDS
perinatal causes
2.8 million
2.5 million
5%
chronic obstructive
pulmonary disease
2.7 million 53
 17 Economic costs

"The art of economics consists in looking

not merely at the immediate but at the
longer effects of any act or policy; it
consists in tracing the consequences of
Global costs of smoking USA, Australia and Europe
that policy not merely for one group but
for all groups." Health care costs associated with
USA (1894-1993) 2002 reports indicate that up to
Henry Hazlitt,
smoking-related illnesses result 10% of health budgets are spent
in a global net loss of US$200 on diabetes-related illnesses.
The costs of cardiovascular disease
billion per year, with one third of
are diverse: the cost to the those losses occurring in

individual and to the family of developing countries. USA

heath care and time off work; the Estimated 1994.
/ "If just 10% of adults began walking
cost to government of health care;
regularly, Americans could save US$5.6
and the cost to the country of lost billion in costs related to heart disease."
- President W. Bush, 2002.
productivity. George

We attempt here to quantify The direct costs of physical inactivity

some of these costs. accounted for an estimated US$24 billion
However,
in health care costs in 1995.
the value of a human life is
Latin America and the Caribbean
beyond our analysis.
Permanent disabilities resulting Health problems related to obesity, such
I

from diabetes cost US$50 billion as heart disease and type 2 diabetes,

in 2000, while costs associated cost the USA an estimated

with insulin, hospitalization, US$177 billion a year.

consultations and care totalled

US$10.6 billion. Cholesterol reducers were the top-sellinc
medications in 2003, generating
US$13.9 billion in sales.
uiooai COSTS or uiaoeies
The American Heart Association
Between 4% and 5% of health
estimates that stroke will cost a total of
budgets are spent on diabetes-
US$53.6 billion in 2004. Direct costs for
related illnesses.
medical care and therapy will average
WHO, 2003
US$33 billion and indirect costs from
lost productivity will be US$20.6 billion.

Price of weekly dose of medication In 2001, the National Stroke Association

Expressed in kg of cheapest crop available (yam, rice or potato) estimated that the average cost per
2003 90 days
patient for the first after a
selected countries stroke was US$15 000, although 10% of
"*'
Mk Simvastatin
-"'' cases cost more than US$35 000.
63.0

^P Aspirin
50.6
50.6

38.4

33.6
30.0

25.7

13.9

4.2

4.0
0.9 1.5 1.4 1.2 0.5 0.2 1.6

Chile China Egypt Georgia Ghana Indonesia Pakistan Sri Lanka Turkey

54
 The economics of CVD

fctto physical exercise stroke

United Kingdom
"The direct cost of obesity to the National Health
Service is 0.5 billion [about US$0.9 billion] per
UK economy
B obesity ^ CVD
year, while the indirect cost to the is

2 billion [about US$3.5 billion]."

at least
- Liam Donaldson, Chief Medical Officer, 2003
cholesterol ^^* tobacco

More than 4% of National Health Service

spending was on stroke services in 2000.

Global costs of heart disease medication

The number of people who die or are disabled

by coronary heart disease and stroke could be

The average total costs of care per patient halved with wider use of a combination of

for sixmonths following a stroke were drugs that costs just US$1 4 a year.
estimated at 16 000 in 2003. WHO, 2002

Stroke was estimated to be responsible for

3% of total health care costs in the

Netherlands in 1994, and 7% of costs for the >mgapore
population aged 75 and over. Stroke ranked hospital costs for stroke were
second on the list of most costly diseases for 2000 as US$5000
/Average
reported in per
the elderly, after dementia, and these costs Ward charges accounted for
patient.
are expected to increase by 40% by 2015. 38%, radiology 15%, doctors' fees
10%, medications 8%, therapy 7%.

The cost of risk factors

Cumulative Medicare costs of treatment of cardiovascular
disease in people aged 65 years to death, in the USA
Lifetime costs of coronary heart disc
Risk factors: US$38044 US$38059
US$ Germany
high blood pressure, US$48
7996
high cholesterol, billion
cigarette smoking, US$
abnormal
US$18604
electrocardiograms,
US$11 711 a history of
US$26
billion Total indirect costs
diabetes or
Total direct costs Lost productivity
previous heart attacks
Including: caused by:
men women men women primary care, short-term and
low risk 3 or more clinical care, long-term disability,
no heart disease risk factors risk factors rehabilitation death

Average cost per case: US$82 000

Expenditure on cardiovascular medications

Percentage of total annual drug expenditure
7989-7997
OECD countries

55
 -

56
PART 4

"Keeping your body healthy is an expression of gratitude to the

whole cosmos, the trees, the clouds, everything."
Most Venerable Thich Nhat Hanh, Vietnamese Buddhist monk (1926)
57
 18 Research
"Science knows no country, because
knowledge belongs to humanity, and is the
torch that illuminates the world."
Louis Pasteur, France (1822-1892)

From the description of how a

heart muscle cell contracts to the

elucidation of the human ogenome,
scientific advances in basic,

clinical, and population research

in cardiovascular disease, and Regional research
Percentage of publications on
their
global impact, have been CVD by region
phenomenal. New and improved countries
jndexed in Med | ine
not assigned
treatments have become possible, 2007
and novel markers of future risk
developing
countries _
have been identified.
Yet several key challenges
^m
Eastern

remain. There is a widespread Europe

lack of research capacity,

standardized data, communication

BARBADOS

networks, and human and TRINIDAD

h TOBAGO
financial resources, in
especially

developing countries.
The MONICA (Multinational .**
MONItoring of trends and
determinants in CArdiovascular

disease) Project involved teams Clinical trials

from 38 populations in Number of published clinical trials on

2 1 countries from the mid- 980s 1 humans in any language in the National

to the mid-1990s, the such Library of Medicine's PubMed

largest
2004
collaboration ever undertaken. It

was set up to explain the diverse

1 83 Road traffic accidents
trends in cardiovascular disease

mortality observed from the 6539

1970s onwards. The project
monitored a
study population of
10 million men and women, aged
25 to 64 years.
MONICA was important in
measuring levels and trends in
cardiovascular diseases and their
risk factors in different

populations, in monitoring
prevention policies in different

countries, and in demonstrating

the importance of the new acute
and long-term treatments that
were being introduced.

58
 CVD
Number
7997-2007
^^i
research publications

of publications on cardiovascular disease indexed in Medline

Top three countries

r*

Research funding by the National Institute of Health in the USA

Spending on disease research
on/r:
 19 Organizations
"Don't agonize. Organize." World Health Organization
Florynce Kennedy, Lawyer, and Civil and
headquarters, Geneva
Womens' Rights Activist (1916-2000)

The World Health Organization's

Cardiovascular Disease

Programme is conducted through

its Geneva headquarters, and

regional
and national offices

worldwide. The World Heart

Federation helps people achieve a
better
life
through
longer, USA
prevention and control of heart

disease and stroke, focusing on

WHO RO Americas/Pan American Health Organizatic

CardioStart International Inc.

low- and middle-income countries.
Cardiothoracic Surgery Network
In addition to the
Children's HeartLink

nongovernmental organizations Congenital Heart Information Network

(NGOs) highlighted here,
there Gift of Life International Inc.

are many international NGOs - HeartGift Foundation

Heart-to-Heart International
from the World Medical
Heart-to-Heart Int. Children's Medical Alliance
Association to Consumers
International Children's Heart Foundation
International that include
Mexico
International Children's Heart Fund
cardiovascular disease control as InterAmerican International Hospital for Children (IHC)
Society of Cardiology International Stroke Society
part of their activities.
Loma Linda University Overseas Heart Surgery Team
Only international and regional
Save A Child's Heart Foundation
organizations
are shown here.
World Heart Foundation
Not mentioned are the many Heart of the Americas
national organizations, whose InterAmerican Heart Foundation

impact may extend outside their

own country, such as the Centers

for Disease Control and
Prevention in the USA, the
British Heart Foundation, and
ThaiHealth in Thailand. Other
national NGOs also work part
time on CVD issues.
There are numerous other World Conferences on Cardiovascular
in a vast arena of varied
partners
but related interests, including World Congresses of Cardiology International Conferences on

organizations
involved with Preventive Cardiology
women, youth, law, economics,
human rights, religion and 1
st
1974 Buenos Aires, Argentina lt 1985 Mosom, USSR
development. 2" (l
1978 Tokvo, japan 2nd 1989 Washington, DC, USA
The
capacity of virtually all V' (1
1982 MOM <m , Russian Federation 3"! 1993 Oslo, Nor\\a\
cardiovascular disease control 4 th 1986 USA 4 th 1997 Montreal, Canada
Washington, DC,
organizations
is
inadequate to 5''
1
1990 Manila, Philippines 5 th 2001 Osaka, Japan
meet the challenge of the CVD 6 th 19^4 Berlin, (ii-i-mam 6 th 2005 Iguassu,
Bra/il

th 1998 Rio do Janeiro, Brazil

epidemic. 7
8 th 2002 Svdnov, Australia
60 l " 1 '
2006 Barcelona, Spain
 CVD organizations
United Kingdom
World Federation of Neurology
WHO, Headquarters (HQ) and regional offices (RO)
European Heart Institute
International CVD organizations

Belgium CVD
Regional organizations
European Heart Network
 20 Prevention: personal choices
and actions
"No matter how far you have gone
on the wrong road, turn back."
Turkish proverb

Good control of blood pressure, Personal choices in lifestyles and behaviour

blood cholesterol and blood sugar
levels, and other cardiovascular
1 Take moderate physical activity for a total
risk factors is the key to reducing of 30 minutes on most days of the week.

risks of heart disease and stroke. 2 Avoid tobacco use and exposure to
Personal behaviour and lifestyle environmental smoke; make plans to quit if

choices can make a

big difference you already smoke.
to the risk of coronary heart
3 Choose a diet rich in fruits, vegetables and
disease and stroke. It is estimated
potassium, and avoid saturated fats and
that
having a high-risk lifestyle calorie-dense meals.
may account for 82% of coronary
4 Maintain a normal body weight; if you
events in women. Here, we
are overweight, lose weight by
identify personal
choices that can

lower individual risk for heart

increasing physical activity and

disease and stroke. The choices reducing calorie intake.

5 Reduce stress at home and at work.

apply to young people and adults
alike.

Personal actions for safeguarding cardiovascular health Young people

1 Discuss all questions with your health care provider. 1 Actions and choices for children and
adolescents with cardiovascular disease, or
2 Have regular check-ups from your health care provider.
risk factors, should be discussed with a
3 Have your blood pressure and levels of blood sugar and
-^ paediatrician or health care provider.
cholesterol checked.
Choose a diet containing a variety of fruits,
4 Follow your health care provider's
vegetables, whole grains, dairy products, fish
instructions regarding physical
legumes, poultry, and lean meat.
activity, nutrition,
weight
There is no need to restrict fat intake in
management, and any medications
children under two years of age.
you have been prescribed.
5 Know the signs and symptoms
4 For children over

of heart attack and stroke and

two years and

remember that both conditions adolescents,

limit foods high
are medical emergencies.
in saturated fats
6 Know your blood pressure and
(to less than
cholesterol level, and keep them
10% of daily
at the recommended levels
calorie intake),
through lifestyle changes and
cholesterol (to less
by taking any prescribed
than 300 mg per
medication.
day), and
7 Lower your total fat and
trans-fatty acids.
saturated fat intake in
Increase physical activity, and
accordance with your health
avoid tobacco use or exposure to
care provider's instructions.
environmental tobacco smoke.

62
 Eat fruit and cereals
Percentage reduction in risk
in tzke
with each daily increment of 10 g of dietary fibre

reported 2004

all coronary events

30%
^P coronary deaths _
7(y
25%

16%
14%
10%

Fibre intake

total dietary fibre cereal fruit

The benefits of stopping smoking

Time since last cigarette Effect

20 minutes Blood pressure and pulse rate drop to normal.

1
day Probability of heart attack begins to decrease.

3 months Circulation improves.

1
year Excess risk of coronary heart disease is half that of a continuing smoker.

5 to 1 5 years later Risk of stroke is reduced to that of people who have never smoked.

1 5 years later Risk of coronary heart disease is similar to that of people who have
never smoked, and the overall risk of death almost the same, especially
if the smoker quits before illness develops. 63
 21 Prevention: population
and systems approaches
"Thinking well is wise; planning well,
wiser; doing well wisest and best of all." Noncommunicable disease (NCD) prevention and control
Old Iranian proverb
Percentage of countries with integration of components
of NCD prevention and control programmes in primary health care
health in 2007
Significant gains
cardiovascular health can be made WHO regions 940/Q
88% 880/0
within short time spans, through

public health and treatment 65%

interventions that have an impact
on large segments of the
population.
As shown here, there is a
gap
between what is known and what
is done in
practice, for
both

prevention and treatment of Minca

Africa Americas tasicrn
Eastern Europe South-East Western
cardiovascular disease. Mediterranean Asia Pacific

Governments are stewards of

health resources, and have a

fundamental responsibility to

protect the health of citizens.

Ministries of Health and the

health profession can play various

roles in CVD, by EASTERN

reducing WESTERN
MEDITERRANEAN
making data available, educating
PACIFIC
the public, making treatments
affordable and available, advising

patients on healthy living

practices, and advocating for

policy and environmental change.

These have been the essential

messages of the International

Heart Health Conferences and the
Availability of equipment for high blood pressure
related declarations on heart
Percentage availability of basic equipment
for diabetes
health. at primary health care level for diagnosis and

management of high blood pressure and diabetes

2001 96% 97% 96%
WHO 94%
regions
86%
81%

n
UK dieticians promote the benefits
for heart health of eating oily fish,
more fruit and vegetables, and less

saturated fat.

Africa Americas Eastern Europe South-East Western

64 Mediterranean Asia Pacific
 Bh
Medical professionals
Number of medical professionals working in cardiologists
noncommunicable disease control
000 population primary health care physicians
per 100
2007 nurses
WHO regions 685

56

247 0.3
0.4
13

Africa Americas
I
Eastern
Mediterranean
Europe South-East
Asia
Western
Pacific

Antihypertensive drugs
Percentage of countries in each re

are available, affordable to low in

or manufactured locally

2007
WHO regions
 22 Health education
"Education is the most powerful weapon
which you can use to change the world."
Nelson Mandela, South Africa (191 8-)
World Heart Federation event

For successful prevention and

participating countries The Victoria Declaration
control of the cardiovascular and territories 2003
on Heart Health
disease epidemic, changes to
Heart Health Declarations
policy, legislation
and taxation are
See Milestones pp76-81
not enough. These interventions The Victoria Declaration
for further details
on Women, Heart
will not be effective if there is no
Disease and Stroke
public understanding, support
and demand for them. Some areas and local support for effective

lie
beyond legislation
for school health programmes or
example, the choice of food for "health-promoting schools".
families, the amount of salt added Guidelines have been developed
in
cooking, whether or not to on various factors that affect

smoke and here health health, such as tobacco, diet and

education is essential to promote physical activity.

healthy choices. The WHO Global School-based

Schools provide an ideal venue Student Health Survey is aimed at

for health education. They can adolescents aged 13 to 15 years,

teach about risk factors, refusal
skills, and the strategies of the
tobacco and food industries. For
example, young people can
and covers nine risk or protective
factors.
Survey results will
provide information on trends
over time, which is useful for

analysehow tobacco industry formulation of risk reduction

promotion attempts to policies.

manipulate them by equating

smoking with growing up, World Heart Day Themes World Heart Day Activities 200?
freedom and being cool.
2000 Physical Activity medical activities
Increasing O and
O knowledge, '

2001 A Heart for Life (e.g. blood pressure

changing beliefs, attitudes and ]

2002 Nutrition and Physical testing)

intentions, on their own are not

to change behaviour. Activity

enough
activities to
School programmes must also
engage the public in
lead by example, by making I
f

physical activity

healthy food available, providing

exercise facilities, prohibiting
scientific activities
tobacco use at all school facilities
conferences
(e.g.
and events, and helping students or workshops)

and staff lose weight and quit

smoking. Ideally, these activities activities

should be part of a coordinated to advocate for a

2003 Women, Heart heart healthy diet
school health programme,
Disease and Stroke
reinforced by community-wide
2004 Children, other activities
efforts.
(e.g. charity
Adolescents and
The WHO Global School gala, dance,
Heart Disease concert, carnival)
Health Initiative is
designed to
2005 Obesity /
strengthen international, national

66
The Catalonia Declaration

Investing in Heart Health

The Osaka Declaration: Health,

Economics and Political Action

Stemming the Global Tide

of Cardiovascular Disease

The Milan Declaration:

Positioning Technology to
Serve Global Heart Health

998 Singapore
The Singapore Declaration:
Forging the Will for Heart
Health in the Next Millennium

valuation of World Heart Days 2000-2003 Giving up smoking: International Quit and Win

Number of participating countries and territories 1994-2002, 2004 projected

Up to 25% of participants in the International
Quit and Win Campaign are off tobacco after one year

000000

till
1

Number of participants
2000 2001 2002 2003 420 000
2002

200 000
2000
Number of 60 000 70000
website hits more than 1998
2 000 000
1994 1996

Number of countries 48

1998

2000 2001 2002 2003

67
 23 Policies and legislation
"The welfare of the people
is the ultimate law."

So/us Populi Supreme Est Lex.

Cicero (1 06 BCE-43 BCE)

Laws, treaties, policies and

regulations
have played important
roles in the prevention and

control of disease. Only

governments can legislate for

health warnings on cigarettes,
introduce mandatory food
standards and labelling, crack
down on smuggling, set a "pro-
health tax policy", or implement
national transport policy. Often

governments are the main

providers of health care; they
decide how funding is allocated,
from prevention programmes to
treatment, research, and training.
The first international

convention that relates specifically

to cardiovascular disease is the

WHO Framework Convention on

Tobacco Control. It was adopted
without dissent by the World
Health Assembly in Geneva in

May 2003, and is

currently in the
process of ratification. Once
40 countries have ratified the
Convention, it will come into

effect as a
legally binding treaty
amongO those countries. The
Convention includes clauses on

advertising bans,
smoke-free Cardiovascular disease plans
areas, health warnings, taxation, worldwide
smoking cessation and smuggling. Percentage of countries by region
with national plans for CVD prevention and control
2007
WHO regions

Africa 8%

Americas

Eastern Mediterranean

South-East Asia 50/o

Western Pacific 4QQ/0

 Smoke-free workplaces

Smoke-free areas in government buildings

2004 or latest available data
r^ Smoking in private workplaces banned.
Exceptions or limited restrictions may
smoking banned
apply to restaurants, bars,
and other venues.
smoking restricted

not regulated First five countries to ratify

the Framework Convention on
unknown Tobacco Control.

1970 Singapore: smoking banned in buses,

cinemas, theatres and other specified
buildings.

Legislation
Percentage of countries by region
with tobacco, and food and nutrition legislation
2007
WHO regions

^ tobacco

? food and nutrition

Africa Americas Eastern Europe South-East Western

Mediterranean Asia Pacific 69
 24 Treatment
"If you do not repair your gutter, you will Cardiac rehabilitation
have your whole house to repair."
Percentage of people with established
Old Spanish proverb
coronary heart disease advised
to participate in cardiac rehabilitation
In 1931, Paul
Dudley White 2007
noted that there was no specific selected European countries

treatment for coronary heart

disease. He described the

treatment of high blood pressure

as "difficult and almost
hopeless".

Today, effective and relatively

inexpensive medication is
available to treat nearly all

cardiovascular diseases,
including
high blood pressure.
in
Improvements surgical

techniques have led to safer

operations. Effective devices have
been developed, such as

pacemakers, prosthetic valves,

and patches for closing holes in
the heart. Other developments
have led to a wide array of
interventions that often make
surgerv unnecessar7-
Together,
o these advances in
71%
treatment improve quality of life
and reduce premature death and

disability. They
also add to the Patients reaching blood pressure and

rising
costs of health care.
Increasingly, high-technology
procedures are chosen over
expensive, but nevertheless
effective, strategies.
In addition, marked
blood cholesterol goals during treatment
Percentage of people aged 70 years or below with established CVD who achieve blood pressure
goal of less than 140/90 mmHg, or blood cholesterol goal of less than 5.0 mmol/l
less
2007
selected European countries
disparities
^ blood cholesterol goal achieved

46%
in the
quality of treatment can be
50%
seen in groups of different race,
23%
ethnicity, sex, and socioeconomic
55%
status. In essence,
many patients
who could benefit from treatment
remain untreated, or inadequately
treated. In future, increased

emphasis needs to be placed on

the appropriate use of proven

treatments for everyone with

coronary heart disease or stroke.

70 63<>/o
Types of treatment Simple secondary
ACE
inhibitors
25% prevention
Selected medication, devices and operations
medication treatments
Percentage reduction in card
Medication used in treatment of 250/0
aspirin risk of heart attack,
two-year
stroke or death from CVD
1
High blood pressure
in patients with previous
2 Coronary heart disease coronary heart disease
or stroke
3 Heart failure 2002

4 Arrhythmia (heart rhythm disorders)

5 Blood clotting disorders

Devices

1 Pacemakers
Diabetes treatment
2 Implantable defibrillators Percentage of persons with diabetes
being treated with medication or special diet

3 Coronary stents 2002-2003

selected countries
4 Prosthetic valves

5 Artificial heart

Operations

1 Coronary artery bypass

2 Balloon angioplasty

3 Valve repair and replacement

4 Heart transplantation

5 Artificial heart operations

Trends in cardiovascular operations and

in the USA
Number of operations and procedures

7987-2007
thousands
*
heart catheterization

^'
open heart surgery

coronary artery bypass surgery

f carotid endarterectomy

* cardiac pacemakers

1981 1986 1991 1996 2001

71
*

s
PART 5

THE FUTURE AND THE PAST

"Let my heart be wise,

It is the gods' best gift."

Euripides Medea, 431 BCE

73
 25 The future
"Unless current trends are halted or reversed,
over a billion people will die from
"I never think of the future - it comes cardiovascular disease in the first half of the
soon enough."
21st century. The large majority will be in
Albert Einstein (1879-1 955)
developing countries and much of the life years
will be lost in middle age. This would be an
I Inlike I
instein, \\e have ID iliink
enormous tragedy, given that research in the
ol the lui m .
.
HI-
|)l.in
n. P\\ ,
to
last half of the 20th century showed that
reduce (In- numbers ol deaths cardiovascular disease was largely preventable."
I'roin
coronary heart disease .mil

stroke. Anthony Rodgers, Clinical Trials Research Unit,

University of Auckland, New Zealand, 2004
Predictions arc by dicir nature

.speculative. Nevertheless,
tliis

nun li is certain: the gloh.il DALYs

epidemic of cardiovascular disi-asc

nol
is
only increasing, hut also
from developed to
shifting

developing nations.
Action can work. There are
MMI mily ahout 800 million

people with high hlood pressure

1

worldwide. Studies now indicate

that in North America, Western

Kurope, and the Asia Pacific

region, each 10 mmllg lowering
ol hlood pressin [|
systolic
.

assoi iated with a decrease in risk

ol stroke ol approximately one

third, in people aged (>() to 7 C)

years. (Jobally, if diastolie blood

pressure (l)UI') can he redu. d h\

i

2%, and by 7% in those with DBP

l
over- )S a million deaths a
mmllg,
yi
.n li HI. n \ heart disease

and stroke could he averted hy

2020 in Asia alone.

No matter what advances there

are in high technology

medicine, the rundameiit.il

message is that am major

reduction in deaths and

disability I'rom ('VI ) will

i Mini liom prevention,

not i ure. This must

involve robust reduction

of risk (actors.
 RISK
FACTORS
that a restricted diet
"might greatly emotion, stress and anger in
symptoms as he was reluctant to
retard the
progress" of coronary precipitating coronary death. apply his ear to the chest.

heart disease. Hunter himself suffered from

angina pectoris and died suddenly 1838 France Louis Rene Lecanu
1677-1761 England Stephen Hales, alter a violent
argument with a showed that cholesterol was
an English clergyman and scientist, hospital colleague. present in human blood.
first measured blood pressure In

inserting
a brass tube into the 1785 England William Withering 1841 Austria Carl Von Rokitansky
artery of a horse. This was a described the use of digitalis in championed the thrombogenic
scientific
experiment, published in coronary heart disease in his
theory, proposing that deposits
1733, demonstrating that the heart monograph An Account of the observed in the inner layer of the
exerts pressure in order to pump Foxglove. Foxglove had been used arterial wall derived primarily
blood. The horse died. tor centuries bv American Indians. from fibrin and other blood
elements rather than being the
1745-1827 Italy
Alessandro Volta 1791 Italy
result of a purulent
process. This
discovered that electric energy was
Luigi
Galvani theory came under attack from
produced by heart muscle discovered that Rudolf Virchow.
contractions. electrical

stimulation of a 1843 Vogel showed that

J.
H
1 749-1 832 England Edward
Jenncr, better know for smallpox
L frog's
heart led to
contraction of the
cholesterol was present in
atherosclerotic plaques.
vaccine, made the essential link cardiac muscle.
between angina pectoris and 1 844 Denmark
disease of the 1799 England Caleb Hillier found
coronary arteries. First
pathology
something hard and gritty in the report of plaque
1752-1832 Italy Antonio Scarpa coronary arteries during an rupture in a
f-t-
autopsy and "well remembered
described arterial aneurvsm.
coronary artery
looking up to the ceiling, which in Bertel

1772 England was old and crumbling, conceivii Thorvaldsen,

William Heberden that some plaster had fallen down". the celebrated

(1710-1801) He discovered, however, that the neoclassical

described angina vessels had hardened, and stated Danish and sculptor, who
artist

pectoris: "they who that "a principle cause of the died of sudden cardiac death in the
are afflicted with it, is to be looked
syncope anginosa Royal Theatre in
Copenhagen.
are sei/ed while for in disordered
coronary
thev are
walking (especially if it be arteries". 1 850 Ventricular fibrillation first

uphill, and soon after eating) with a described.

painful and most

disagreeable 1815 England London surgeon
sensation in the breast, which seems 1850s Ophthalmoscope invented,
Joseph Hodgson claimed
as if would extinguish inflammation was the underlying
life if it
O direct visualization of
it allowing
were to increase or to continue; but cause of atherosclerosis and it was arteries at the back of the
eye.
the moment
they stand still, all this not a natural degenerative part of
uneasiness vanishes". He was also the 1852 England Fatty material in the
ageing process.
the to write about
coronary arteries described by
first Sir

byperlipidaemia as a risk factor 1815 France M.E. Chevreul name Richard Quain, which he
when he noticed that the serum of the
fatty
substance extracted from attributed to nutrition. He linked
an obese patient who from the the fatty heart to "languid and
suddenly died gallstones "cholesterol"
O
was "thick like cream". Greek "khole" (bile) and "stereos" feeble circulation, a sense of

(solid). uneasiness and oppression in the

1775 Scotland John Hunter (1728 chest, embarrassment and distress

1793), a surgical pathologist, 1819 France Rene Theophile

wrote "in a sudden and violent Laennec (1781-1826), invented
transport of anger, he fell down the stethoscope. He rolled paper
and expired into a cylinder while
immediately", examining a
illustrating
the importance of young
J o woman with cardiac
f
 advertisements said that the drug
o
did "not affect the heart".

1906 Germany M. Cremer, first

1856 Germany
oesophageal ECG
by professiona a
Rudolf Virchow,
sword swallower. First fetal ECG
a Pole, believed
from the abdominal surface of a
that disease
pregnant woman.
occurred at

cellular level,
1 907 England First case
report of
and also
atrial fibrillation
by Arthur Cushnv
described
professor of pharmacology at
cerebral emboli
University College, London.
causing stroke. Virchow also
emphasized the societal causes of 1912 James B. Herrick described
disease as "disturbances of human
heart disease resulting from
:

culture".
hardening of the arteries.

1867 England Lauder Brunton,

1912 First human cardiac
pharmacologist, discovered that catheterization (no X-ray
amyl nitrite relieved angina. visualization) Frizt Bleichroeder,
by
lIIlXEtCEII
1872 France Gabriel
E. Linger and W. Loeb.
Lippmann
invented the capillary
1915 USA Establishment of
electrometer, the precursor of the New York
organization in City,
electrocardiograph .

which became the American Heart

Association.
1893 Holland Willem Einthoven
(1 860-1927) introduced the term 920 USA First ECG of acute
electrocardiogram or ECG/EKG;
yocardial infarction by Harold
five deflections
distinguished
PQRST (1895); constructed the
first in 1901,
electrocardiograph 1923 USA First
operative widening
which weighed 270 kg, occupi
of scarred cardiac valve by
two rooms and required five
E. Cutler and S.A. Levine.
people to operate it; transmitte
the first ECG
from hospital to his ^L
1925 United Kingdom Widening of
laboratory 1 . 5 km away via narrowed mitral valve by Souter,
telephone cable (in 1905); who stretched the valve ring with
published the first normal an<
his fingers.
abnormal ECGs (1906) and won
the Nobel Prize (1924).

1 895 Germany Physicist

Wilhem
Konrad Roentgen (1845-1923)
1948 USA California physician 1954 United Kingdom First carotid 1960 USA First
a\\ rrnce Craven noticed that 400
endarterectomy by Eastcott, replacement of
I

of his male patients who took Pickering and Rob. heart valve with

aspirin tor two years had no heart Starr- Ed wards

attacks.
By 1956, he had 1954 India Called on WHO to mechanical valve,
chronicled the health of 8000 address the coming epidemic of
developed by
patients taking aspirin and found cardiovascular disease in Albert Starr (left)
no heart attacks in the group.
developing countries. and Lowell
Edwards.
1948 USA Start of the
Framingham '55 United
Kingdom First
reportec
Heart Study where, for the first itral valve replacement by Judson 1961 USA Framingham Heart
time, a large cohort of healthy men Chesterman. Study investigators coined the term
and women were studied "risk factors" for the
development
prospectively. 950s Minimization of bias for the of coronary heart disease. High
le assessment of cholesterol level, blood pressure,
1949 USA Portable Holter Monitor cardiovascular treatments by and electrocardiogram
invented bv Norman Jeff Holter to introduction of randomization into abnormalities found to increase the
record ambulatorv ECG. clinical trials (at
instigation
of Sir risk of coronary heart disease.
Austin Bradford Hill). -j-4
1950 The International Society of 1961 USA First use of external

Cardiology established, later joined 1956 USA First

report of the cardiac massage to restart a heart
with International Cardiology successful ending of ventricular
byJ.R. Jude.
Federation and renamed World fibrillation in humans by externally
Heart Federation. applied countershock published by 1961 USA First direct current
Dr Paul Zoll. dcfibrillation with external
paddle;
1 950 Canada First
pacemaker by Bernard Lown and Barough
invented by John Hopps. 1957 First Berkowitz.
battery-powered
external pacemaker.
1952 USA First
prosthetic valve 1960s First human implant of

implanted in aorta
by surgeon 1958 USA Seymour Furman totally implantable pacemak
Charles Hufnagel. inserted a pacemaker in a patient
lived for 96 1964 USA First transluminal
days.
1952 USA human angioplasty performed on a
First successful

open heart surgery under 1958 Sweden Internal long-term narrowed artery in the leg by-
hypothermia bv Walton Lillehei cardiac
pacing by Ake Senning. Charles T. Dotter.
and John Lewis, who implanted
the synthetic valve in a
first 1 958 Start of development of a 1965 USA Michael DeBakey am
live year-old girl who had been selective coronary Adrian Kantrowitz implanted
angiography
born with an atrioseptal defect procedure by Mason Sones. mechanical devices to help a
(hole in her heart). diseased heart.
1959 WHO established
1952 USA External cardiac Cardiovascular Diseases 1967 South Ajrica First whole heart
._
pacemaker designed by Paul Zoll.
programme. transplant from one person to
;"- another by Dr Christiaan Barnard.
1953 USA First 1 960s High blood pressure
demonstrated identified as a treatable risk factor 1967 USA Saphenous vein coron
coronary artery for stroke .
bypass graft by Dr Rene Favaloro.
disease
among
young US 1960 USA First
Coronary Care 1967 Framingham, USA Physical
soldiers killed in Unit in
Bethany, Kansas. inactivity
and obesity found to
action in Korea increase the risk of heart disease.

(later observed in 1960 Framingham, USA Cigarette

the casualties of the Viet Nam Wa smoking found to increase the risk

too) by William F. Enos, Robert of heart disease.

H. Holmes and James Beyer.
 resulted in reduction of coronary 1983 USA List of 246 coronary risk
heart disease through community- factors published by Hopkins and
>ased interventions that change Williams (list now much longer).
risk factors such as
lifestyle-related
1969 USA First use of artificial
habits and 1980s Minimization of random
physical activity, dietary
heart in human by Denton Cooley. tobacco use. error for the reliable assessment of
cardiovascular treatments by
1972 USA The Stanford Three 1977 Framingham, USA Effects introduction of large-scale "mega-
Community Study started (later described of triglycerides and LDL- trials" (at
instigation
of Sir Richard
becoming The Stanford Five-City and HDL- cholesterol on heart Peto).
Project); this showed a 23% disease.
reduction in coronary heart disease 1 986 France First coronary stent
risk caused
by community-based 1978 Framingham, USA implanted by Jacques Puel and
interventions that change lifestyle- Psvchosocial factors found to affect Ulrich Sigwart.
related risk factors such as physical heart disease.
activity, dietary
habits and tobacco 1987 Japan M. Okada used a laser

1978 Australia North Coast Healthy to burn channels in the heart

Lifestyle Programme showed muscle to help revascularize the

1972 Finland North Karelia Project reduction in heart in patients with coronary
significant
5 smoking.
&
began, aimed at preventing heart disease.
cardiovascular disease among 1978 Switzerland Swiss National
residents. Cardiovascular mortality Research Programme community 1 987 Framingham, USA High blood
men, aged between
rates for trial resulted in cholesterol levels found to
prevention
35 and 64 years, decreased by 57% reduction of smoking, blood correlate directly with risk of death
from 1970 to 1992.
pressure and obesity.
in
O men.
young
J

1974 Framingham, USA Diabetes 1978 Atrial fibrillation (irregular 1988 Framingham, USA High levels
linked to cardiovascular disease. heart beat) found to increase the of HDL-cholesterol found to
risk of stroke . reduce risk of death.
1970s Aspirin recognized as
preventing heart attacks and 1988 ISIS- 2 trial
i
1979 South Africa Coronary Risk
stroke. Factor Study shows
community
prevention trial resulted in emergency
1970s Development of reduction of smoking, blood treatment for
computerized tomography (CT) to pressure and composite coronary
heart attacks
aid early
diagnosis
of stroke .

heart disease risks. with aspirin and

"clot-
fibrinolytic
1977 1979 Germany First use
by Peter busting" drugs
Switzerland saves lives.
Rentrop of intracoronary
First coronary a clot-dissolving drug
streptokinase, ~~H^H
PTCA to stop a heart attack in progress. 1988 Framingham, USA Isolated
(percutaneous found to
systolic hypertension
transluminal 1981 Framingham, USA Filter increase risk of heart disease.
found to carry as much

He-
coronary cigarettes
angioplasty); risk for coronary heart disease as 1 988 Framingham, USA Cigarette
Andreas risk of
unfiltered cigarettes. smoking found to increase
Gruentzif stroke.
inserted a balloon-tipped catheter 1981 USA Report on relationship
into a coronary artery and inflated 1990 Randomized showed
between diet and heart disease. trials
the balloon, and thus successfully that lowering blood pressure
opened a blockage and restored 1982 USA First permanent artificial lowers the risk of stroke.
blood flow.
heart, designed by Robert Jarvik,
and implanted by Willem DeVries, 1990 United Kingdom Meta-analysis
1977 The Martignacco Project
Italy in a 61 -year-old man.
*
oftrials
by Clinical Trial Service
community prevention trial Unit (CTSU) in Oxford showed
that
lowering blood pressure Ilh/IIla
receptor blockcr drugs Cardiovascular Disease emphasized
lowers the risk of coronarv disease. prevent blood clots; the the global nature of the CVD
importance of inflammation in burden and highlighted the need to
1991 China Tianjin CVD cardiovascular disease recognized;
O address economic and
political
Intervention Programme study on the deadly effects of factors in order to tackle CVD.
community prevention trial led to smoking fewer than 1
cigarettes
the creation of non-smoking
O per day. 2002 United Kingdom The Heart
environments and increased sales Protection Study showed that
1 998
ol low-sodium seasonings. Singapore The Singapo re statins could benefit people with
Declaration: Forging
O O the Will diabetes and those with cholesterol
1 992 Canada The Victoria Heart Health in the Next levels previously
1 J
considered low.
Declaration on Heart Health Millennium.
affirmed that CVD
large
is Iv 2002 USA
preventable, that there is the 2000 Canada The NASA's
scientific
knowledge to eliminate Victoria Commercial
most CVD, and that the public Declaration on Invention of the
health infrastructure and Women, Heart Year Award
capacity
to address
prevention were Disease and
given for the
Stroke addressed
lacking. DeBakey
the importance of Ventricular
1990s USA Hostility science and polic Assist Device,
(including
such as
traits
anger, cynicism, and
in action and the need to tackle based on space shuttle
technology,
mistrust), a major component of gender disparities in health. It and developed by Michael

type A behaviour,shown to be called upon all stakeholders to join DeBakey (above) and NASA
associated with an increased risk of forces and take appropriate actio
engineer David Saucier. The
heart attack and other cardiac to control the cardiovascular
pump, used to treat heart failure,

complications in
healthy persons
disease epidemic. was one-tenth the size of previous
and patients with and was
coronary heart heart-assist devices, first

disease. 2000 World HeartJOay, whu

First used in a
patient in 2000.
has become a global annual event.
1992 China First
heart-lung 2003 Switzerland WHO
transplant in China. 2000 The entire human genome is Framework Convention on
mapped. Tobacco Control adopted at the

mid-1990s Scandinavia, United 56th World Health Assembly.

J

Kingdom, USA Remarkable 2000 WHO 53rd World Health

improvement in survival of Assembly endorsed Global strateg' 2003 Switzerland The World
for noncommunicable disease Health Report:
coronary heart disease patients "Shaping the
treated with statins. (NCD) prevention and control, Future" highlighted CVD as the
which outlines major objectives for of three O
first growingO threats that
1 995 Spain The Catalonia monitoring, preventing and make up the
"neglected global
Declaration:
Investing in Heart managing NCDs with special epidemics". The report called for
Health, and its
follow-up emphasis on major NCDs with action at the national and global
O
convention in 1997, emphasized common risk factors and levels to prevent and control CVD.
the
importance of investments in determinants cardiovascular
heart health and
provided examples disease, cancer, diabetes and 2004 Switzerland WHO Global
of many successful CVD
prevention chronic respiratory disease. Strategy on Diet, Physical
programmes worldwide. Activity and Health endorsed by
2001 Japan The World Health Assembly.
1998 USA Hypertension gene in Osaka
men identified. Declaration: 2004 Italy
Milan Declaration on
Health, Heart Health: Positioning
O
1998 New advances: Economics and Technology to serve Global Heart
gene therapy grows new blood Political Action: Health.
vessels to the heart; the
strong Stemming
confirmation that "superaspirin"
1
Global Tide of
*
%'*
f
PART 6
WORLD TABLES

"Live as if
you were to die tomorrow. Learn
as if
you were
to live forever."

Mahatma Gandhi (1869 1948)

83
World Data Table
Country

Afghanistan
 6
imoking prevalence Diabetes
ol N I'erc enlace ol
Percentage people 1

|>eople
ears and above who smoke ji <l
'II \ears and alxive

.W.J or latest available Jata with dialx-tes

2000

46.2% 22.8%
40.2% 11.5%
49.6% 35.9%

32.0% 18.90/0

67.4% 4.1o/o

30.706 23.1%
37.4% 26.3%
32.0% 1.706

29.5% 16.0%
63.0% 34.506

19.8% 3.0%
63.60/0 22.00/0

33.2o/o 22.906

5.4o/o

36.7% 19.20/0

54.6% 31.5%

29.4% 18.406

47.3o/o 28.206

25.6% 13.2%

6.50/0

20.70/0 2.40/o

30.0o/o 26.6%

19.7% 3.1%
44.1% 36.6%
58.9% 3.6%

30.5% 18.4%
20.806 3.9%

24.3% 10.0%
21.0% 4.0%
41.4% 27.4%
48.8% 28.5%

42.6% 26.2%
40.3% 36.9%
World Data Table
Country
World Data Table
Country
 5

moking prevalence
IN
Percentage ol people
ars and lbove \\lio smoke
1

(Hb i>r Aiiiv ,ir.;i/<iMr i/iitj

nu'ii women
World Data Table
Country
 5 6
Smoking prevalence Diabetes
1'iTii'iitasje of people 18 IVrivntaiy <>l proplr
M-ars aiul above \vlio smoke aged 20 years and alxwe
-003 IT lau-it iiuJi/iiWi' Juta with di.ibrh-s

w,,nu-n ^00
Glossary of terms used in this publication

ACE inhibitors: angiotensin-converting-enzyme Carotid stenosis: narrowing O of the carotid arteries,

inhibitors.
Drugs used to treat high blood pressure, and themain arteries in the neck that supply blood to the
to aid
healing after a heart attack. brain.

Angina (angina pectoris): pain or discomfort in the Cerebrovascular disease: also called a stroke or the
chest that occurs when part of the heart does not brain equivalent of a heart attack. A condition in which a
receive enough blood. Typically, it is
precipitated by blood vessel in the brain bursts or is clogged bv a blood
oo 7
effort and relieved
by rest. clot, leading to inadequate blood supply to the brain and
death of brain cells.
surgical procedure used
a non-invasive
Angioplasty:
to open up blockages in blood vessels, particularly the Cholesterol: a
waxy substance that circulates in the

coronary arteries that feed the heart. Often performed bloodstream.

with either a balloon or a wire mesh (stent).
Cholesterol plaques: deposits of fat, cholesterol,
Anticoagulant: medication that
delays the clotting cellular waste products, calcium and other substances
(coagulation) of blood. that build up on the inner
1 O of an arterv.
lining J

Arrhythmia: a
change in the
regular beat or rhythm of Congestive heart failure: a condition in which the
the heart. The heart may seem to skip a beat, or beat heart cannot pump enough blood to meet the needs of
irregularly,
or beat very fast or very slowly. the body's other
organs.
Arteriosclerosis: a
general term for the hardening of Coronary artery bypass surgery (CABG): A type
the arteries. of heart surgery that re-routes blood around
clogged
or "bypasses" them - to improve the
supply of
arteries
Asymptomatic: without symptoms. This term may
blood and oxygen to the heart.
apply either to healthy persons or to persons with
preclinical (prior to clinical diagnosis) disease in whom Coronary heart disease: heart disease in which the
symptoms are not yet apparent. coronary arteries are narrowed and the supply of blood

Atherosclerosis: one form of arteriosclerosis, where and oxygen to the heart therefore decreased. Also

the
hardening and narrowing of the arteries is caused by
called
coronary artery disease or ischaemic heart
disease. It includes heart attack and angina.
the slow build-up of
fatty deposits
on the inside lining.
o
a
Atrial fibrillation: common
heart rhythm disorder
a Developing country, high mortality: developing
in which the two small chambers of the heart country with high child
mortality and high or very high
upper
adult mortality.
(the atria) quiver instead of beating effectively. This

quivering makes the heart less efficient, allows blood to Developing country, low mortality: a developing
pool and form clots, and predisposes to stroke. country with low child mortality and low adult
Blood pressure: the force of the blood
pushing
mortality.

against the walls of arteries. Blood pressure given is as Diabetes mellitus: a chronic disease due to either
two numbers: systolic pressure (the pressure while the insulin
deficiency or resistance to insulin action or both,
contracting) and diastolic pressure (the pressure
heart is and associated with hyperglycaemia (elevated blood
when the heart is
resting
between contractions). glucose levels).

Body mass index (BMI): a measure of weight in Direct costs: costs associated with an illness that can
relation to calculated as weight (in
It is be attributed to a medical service, procedure,
height.

kilograms) divided by the square of height (in metres). medication, etc., such as X-ray examination,
A BMI than 25 is considered normal, 25-30
of less is
pharmaceutical drugs (for example, insulin), surgery, or
overweight, and greater than 30 defines obesity. a clinic visit.

Cardiovascular disease (CVD): any disease of the Disability adjusted life years (DALYs): a measure
heart or blood vessels, including stroke and high blood of overall burden of a disease by combining the years of
o o
pressure. potential life lost due to premature death and the years
of productive life lostdue to the disability. One DALY
is one lost
year of healthy life.

92
 occurrence community or region of Physical activity: bodily movement
1
tin- in a
Epidemic: that
substantially
cases ol an illness,
specific health-related behaviour, or increases
energy expenditure.
other health-related events
clearly in excess of what Premature death: death that occurs at an
age earlier
would normally be expected.
than the average life for the
expectancy population.
Health: a state of complete physical, mental, and social
Primary prevention: a strategy that helps to prevent
being and not merely the absence of disease or
\u-ll
people who are at
the onset of a disease or condition in
infirmity. risk but do not already have the disease or condition.
HDL (high-density lipoprotein) cholesterol: the Examples are promotion of exercise in the
general
so-called "yood cholesterol". HDL
helps remove population, smoking prevention in
young people, and
cholesterol from the blood vessels.
High levels of blood also the treatment and control of
high blood pressure as
HDL protect against heart disease. a
strategy for
primary prevention of stroke.
Heart attack (myocardial infarction): death of Rheumatic heart disease: damage to the heart
part ol the heart muscle as a result of a coronary artery valves and other heart structures from inflammation and
becoming completely blocked, usually by a blood clot scarring caused by rheumatic fever. Rheumatic fever
in lack of blood flow to the heart
(thrombus), resulting begins with a sore throat due to streptococcal infection.
muscle and therefore loss of needed
oxygen. a
Secondary prevention: strategy that helps to
Heart failure: see Congestive heart failure.
prevent recurrent disease or complications in people
who already have the disease. For example, the use of a
High blood pressure: a
systolic
blood pressure of
140 dose of aspirin by heart attack survivors is an
mmHg or greater or a diastolic pressure of 90 daily

strategy for preventing a second heart attack.

effective
mmHg or greater.
an amino acid produced by the Sedentary: denotes a person who is
relatively
inactive
Homocysteine: body.
Elevated levels of homocvsteine in the blood can and has a lifestyle characterized
by a lot of
sitting.

damage blood vessels and disrupt normal blood Stent: a device used to support tissues while
healing
and possibly increase the risk of heart attack, takes place. A stent can
clotting, keep "tube-shaped" structures,
stroke, and peripheral vascular disease. such as blood vessels, open after a
surgical procedure.
Indirect costs: costs associated with an illness that
Anintraluminal coronary artery stent is a small, self-

occur because an individual or familv members cannot expanding, stainless steel mesh tube, which is
placed
work at their usual jobs, because of premature death, within a coronary artery to keep the vessel
open.
sickness, or disability. Stroke: the brain equivalent of a heart attack.
Ischaemic heart disease: see
A condition in which a blood vessel in the brain bursts
Coronary heart
disease. (haemorrhagic stroke) or is clogged (embolic or
ischaemic stroke) by a blood clot. This leads to
LDL (low-density lipoprotein) cholesterol: the
inadequate blood supply to the brain and death of the
so-called "bad cholesterol".
High levels of LDL put brain cells, and
usually results in temporary or
people at risk of heart attack.
permanent neurological deficits.

Lipid: or fat-like substance, such as cholesterol,

fat
Transient ischaemic attack (TIA): small stroke-like
present in blood and body tissues.
event, which resolves in a day or less. It is often a
MET: metabolic equivalent; a measure of energy
warning sign of an impending stroke.
expenditure. One MET/min the amount of
is
energy
while
Triglyceride: the chemical form in which most fat
expended sitting quietly
at rest for one minute.
exists in food and in the
body.
a condition characterized
Obesity: by excessive body
fat.
Usually defined as a body mass index greater than
30.

Peripheral vascular disease: disease of certain

blood vessels outside the heart or disease of the
lymph
vessels, forexample the arteries supplying the limbs,
which leads to inadequate blood supply and claudication
(intermittent pain on exercise such as walking).

93
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Schooler C, Farquhar JW, Fortmann SP, Flora JA.

Roden DM. Cardiovascular pharmacogenomics.
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108
 Useful contacts

World Health Organization Congress

to
of Neurological
c> Surgeons:
to

http://www.neurosurgeon.org
http://www.who.int Consortium for Southeastern Hypertension Control (COSEHC):

http://www.cosehc.org/
Cardiovascular disease:
East Meets West: http://www.eastmcetswest.org
iliseasfs/
http://www5.who.int/cardiovascular Eastern Mediterranean Network on Heart Health, (EMNHH):
Diabetes:
http://emnhh.homestead.com/files/index.htm
http:// www. who. int /health_topicsAliabetes_mellitus /en/ The Endocrine Society: http://www.endo-society.org/
Diet:
European Association for Cardiothoracic Surgery:
http:
// vvwvv. who.int/health_topics/dict/en/
http://www.eacts.org/
Nutrition:
European Heart Institute:
http:// www. who. int /health_topics/ nutrition /en/
http: / www.european-academy.at
/
( )l>r-.it\ :

European Heart Network:

http: //www. who. int/health_topics/obesity/en/
http://www.ehnheart.org/index2.asp
Public Health Surveillance:
EMASH European Medical Association on Smoking and Health:
/ / www. w ho. int /
health_topics public_hcalth_sur veillance /en /
/
http: /emash. globalink.org/
http: /
Tobacco Free Initiative:
ENSH European Network for Smoke-free Hospitals:
http://ww-w.who.int/tobacco/en/
http://ensh.free.fr/
Centers for Disease Control and Prevention, USA ENSP European Network for
Smoking Prevention:
http://www.ensp.org
http://www.cdc.gov/ European Network of Young People and Tobacco:
http://www.ktl.fi/enypat/
Cardiovascular Health Program:
European Network of Quitlines:
http / / www. cdc gov / cvh /
: .

http://www.quitlines-conference.com/
Nutrition and Physical Activity for Noninvasive Cardiovascular
Program: European Society Dynamics:
http://www.cdc.gov/nccdphp/dnpa/ http://www2.mf.uni-lj.si/~esnicvd/
Tobacco Program:
to
European Society of Cardiology:
// www. cdc / tobacco / /www. escardio.org/
http gov http: /
: .

Diabetes Program:
European Society of Hypertension:
// www.cdc.gov/diabetes/
http: http: / / www.eshonline.org/
Laboratory Sciences Program: European Stroke Initiative:
http://www.cdc.gov/nceh/dls/programs.htm http://www.eusi-stroke.com/index.shtml
Office of Global Health:
European Union of Non-smokers:
http: // www.cdc.gov/ogh/
http://www.globalink.org/tobacco/docs/eu-docs/uene.htm
Behavioral Risk Factor Surveillance System: Framework Convention Alliance (FCA):

http: /
/www.cdc.gov/brfss http: / / www.fctc.org/
National Center for Health Statistics: G8 Telematics Heart Health Project:
http: / /www.cdc.gov/nchs http://www.med.mun.ca/g8hearthealth/
Gift of Life International Inc.:
International and Regional Organisations
http://www.giftoflifeinternational.org/
Asian Society for Cardiovascular Surgery: Global Connection International:

http: / / www.ascvs.org/ http / / ww w. gci world org

: .

Association for European Paediatric Global Cardiovascular Infobase (in English and Spanish):
Cardiology /Association
la http://www.cvdinfobase.ca/
Europeenne pour Cardiologie Pediatrique:
http / / www. aepc org / home htm
: . . Global Healing:
to http://www.globalhealing.org
r b to to

Brain Aneurysm Foundation: Global Health Information Network:

http / / www. bafound org

: .
http: / / www.healthnet.org/
Cairdes: http://www.cairdes.com Global Partnerships for Tobacco Control:
CardioStart International Inc: http: / / www.essentialaction.org/tobacco/

http://www.cardiostart.com/ Globalink, UICC International Union against Cancer:

Cardiothoracic Surgery Network: http:
// www.globalink.org/

http: / / www.ctsnet.org/ Healing the Children:

Chain of Hope: http://www.chainofhope.org http://www.healingchildren.org
Children's HeartLink: Heart Care International:

http: / /www.childrensheartlink.org/ http:

/ /www. heartcareintl.org
Children's Hearts: HeartGift Foundation:
http://www.childrenshearts.org.uk
Clearinghouse for Tobacco Control (South East Asia): http://www.heartgift.org/index.html
The Heart of a Child Foundation - Little Hearts on the Mend:
http://www.prn2.usm.my/pages/about.asp
Coeurs pour Tous (Hearts for All): http / / www. littleheartsonthemend org
: .

http / / www. cptg. ch / fr / start htm

: .
Heart-to-Heart International:

Congenital Heart Information Network: http / / www. hearttoheart org/

: .

http: / /www. tchin.org/

109
Heart-to-Heart International Children's Medical Alliance: International Tobacco Evidence Network (ITEN):
http://www.heart-2-heart.org/ http / /: ww
w. tobaccoevidence net / .

Initiative for Cardiovascular Health Research in

Developing Countries: The Internet Stroke Center:
http://www.globalforumhealth.org/pages/index.asp? http://www.strokecenter.org/pat/organi7.ations.htm
ThePage=page1_OOOS00040001_l.htm&Nav=OOOS00040001 Legacy Foundation, tobacco document site:
Inter American Heart Foundation:
http://legacy.library.ucsf.edu/cgi/b/bib/bib-idx?g=tob
http / / www. interamericanhear t org
: . Mediterranean Stroke Society:
Inter American
Society of Cardiology (in Spanish and English): http://www.hsanmartino.liguria.it/cictus/med.htm
http :// www. soinca org . OTAF L'Observatoire du Tabac en Afrique Francophone:
Inter-American Society of Hypertension: /
http: /otaf.globalink.org/

http://org.umc.edu/iash/homepage.htm: Physicians lor Peace: http://www.physiciansforpeace.org

http://www.musc.edu/iash/generale.htm ProCOR: Conference on Cardiovascular Health:
International Academy of Cardiology: http://www.procor.org/
http://www.cardiologyonline.com/ Project Hope: http://www.projecthope.org

Agency on Tobacco and Health (IATH):

International Project Kids Worldwide:
Email: admin@iath.org
^~s o http: / /www.projectkidsworldwide.org
International Atherosclerosis Society: Project Open Hearts:
http://www.poh.org
http / /
: w ww.athero. org/ Repace's site, especially
on passive smoking (Jim Repace):
International Children's Heart Foundation: http://www.repace.com/
http://www.ichf.org/ Save A Child's Heart Foundation:
International Children's Heart Fund:
http://www.saveachildsheart.com
http://www.ichfund.org/ Society for Research on Nicotine and Tobacco (SRNT):
International Diabetes Federation: http: / / www.srnt.org/

http:
//
www.idf.org/ Smokescreen Action Network:
International Diabetes Institute, Australia: http://www.smokescreen.org
http :// www. diabetes com au / home htm
. . . Southeast Asian Tobacco Control Alliance:
International Federation of Sports Medicine: http: / /www. tobaccofreeasia.net/
http://www.fims.org/ Stroke Awareness for Everyone:
International Hospital for Children (IHC): http://www.strokesafe.org/
http: / / www.healachild.org Stroke Clubs International:
International Network of Women against
Tobacco (IN WAT): Email: strokeclub@aol.com

http://www.inwat.org/ Stroke Net:

International Network towards Smoke-Free Hospitals (INTSH): : / / www. strokenet info /resources/ stroke / internationalsites. htm
.
http
http://intsh.plobalink.org/
r o o Surgeons of Hope Foundation:
International Non Governmental Coalition against Tobacco (INGCAT): http / / ww w. surgeonsofhope org
: .

http://www.ingcat.org/
r o o Tobacco, org http / / www. tobacco, org
: :

International Obesity Task Force: Tobacco Control journal:

http://www.iotf.org/ http / /
: w w w. tobaccocontrol com
.

International Pediatric
Hypertension Association: Tobacco Control Resource Center /Tobacco Products Liability Project

http://www.pediatrichypertension.org/ (TCRC/TPLP): http://tobacco.neu.edu/

International
Society for Adult Congenital Cardiac Disease: TCRC Tobacco Control Resource Centre, BMA, UK:
/
http://www.isaccd.org/ http: /www.tobacco-control.org/
International Society for
Aging and Physical Activity: Tobacco Control Supersite:

http://www.isapa.org/ http / / www. health .usyd.edu.au/ tobacco /

:

International
Society for Cardiovascular Surgery: Tobacco Documents Online (TDO, Smokescreen:

http://www.vascsurg.org/doc/ S76.html##.htm 1
http:
/ /www. tobaccodocuments.org
International Society for Heart Research: Tobaccopedia:
http / / www. ishrworld org/
: .
http:
//
TobaccoPedia.org
International
Society for Heart & Lung Transplantation: Treatobacco Database & Educational Resource for Treatment of

http://www.ishlt.org/ Tobacco Dependence:

International Society for Minimally Invasive Cardiac http://www.treatobacco.net/
Surgery:
http://www.ismics.org/ World Federation of Neurology:
International Society for the Prevention of Tobacco Induced Diseases http://www.wfneurology.org/
(PTID): http://www.ptid.org World Heart Federation:
International
Society of Cardiovascular Ultrasound: http://www.worldheart.org/
http://www.iscu.org/ World Heart Foundation:
International Society of Hypertension: http://www.world-heart.org/
http://www.hypertension2004.com.br/ World Hypertension League:
International Society of http ://www.mco.edu/ org / whl
/
Nephrology:
http: / / www.isn-online.org/ World Kidney Foundation:
International Society on Hypertension in Blacks (ISHIB): http / / www. worldkidneyfund .org/
:

http: //www.ishib.org/main/ishib_opcn. htm World Medical Association:

International Stroke http://www.wma.net/
Society:

http://www.internationalstroke.org/index.php
International Task Force for the Prevention of
Coronary Heart Disease:
http://www.chd-taskforce.de/

110
 Index

activity
see
physical activity and prevention of 62 63, 6465, 66- diabetes mellitus 48

inactivity 67, 68, 80, 81 hypertensive heart disease 18, 48

ACE inhibitors 40, 71,92 research into 58-59, 75 inflammatory heart disease 1 8
age, advancing 19, 25,
42 risk factors 24 43 physical inactivity 35
alcohol use 19, 24-25 surgery 70-71, 75, 78, 79, 80, 81 rheumatic heart disease

ancurysm see aortic

aneurysm and types of 18-19 18, 20-21
dissection carotid stroke 18-19, 48, 50-51, 52-53,

angina pectoris 32, 77, 78 endarterectomy 71 74

angioplasty 71, 79,
92 stenosis 52, 92 tobacco use 74

anticoagulant
92 cars see motor vehicles deep venous thrombosis 1 9

antihypertensive drugs 65 Centers for Disease Control and diabetes mellitus 19, 25, 34, 38-39,
aortic
aneurysm and dissection 19, 32 Prevention (USA) 60 40-41,42,48, 52, 63, 64, 75,
arrhvthmia 71 92 ,
cerebrovascular disease see stroke 80, 81,92
arteriosclerosis 76, 92 childbirth 19 deaths from 48
artificial
body parts 71 , 75, 80 children and youth 2021, 25, economic costs of 54
arterial disease, peripheral 19, 32, 76 26-27, 38, 51, 62, 66 predicted number of people with
aspirin 55, 65, 71, 78,79, 80, 81 cholesterol 19, 24-25, 30-31, 40, 75
atherosclerosis 26, 31, 32, 42, 77, 92 42,48, 62, 65, 70-71, 77, 79, research into 58-59
atrial fibrillation 19, 20, 50, 52, 78, 80, 81, 92 treatment of 7 1
80, 92 HDL (high-density lipoprotein) type 1 diabetes 38

25, 30, 32,42, 80, 93 type 2 diabetes 26, 36, 38, 54

beta-blockers 71 LDL (low-density lipoprotein) diet 19, 24-25, 26, 28, 36, 42, 48,
blood clotting
O 25, 30, 32, 80, 93 52, 62-63, 64, 66, 77, 80;
disorders 19, 25, 32; see also
plaques 32, 77, 92 see also food
stroke cigarettes
see tobacco use
digitalis
77
treatment of 80, 81 clotting
see blood clotting life
disability-adjusted years (DALYs)
blood pressure 28-29, 32, 48, contraceptive, oral 19, 25, 42, 50 46-4-7, 50-51, 74, 92
62-63, 66, 70, 77, 78, 80, 92 coronary
high 19, 24-25, 26, 28-29, 32, artery bypass surgery 71 ,
92 economic costs 5455, 75, 92, 93
34, 40, 42, 50, 52, 63, 64, 70, artery disease 79 education
79, 93 artery spasm 32 health 66 67
see also
hypertension and stent71, 80, 93 level of 19, 28, 40,41
hypertensive heart disease see also cardiac and heart
electrocardiogram (ECG) 78, 79
blood sugar levels 62 coronary heart disease 19, 32, embolism see
pulmonary embolism
body mass index (BMI) 36-37, 92 34-35, 40, 52, 92 ethnicity
and race 25, 42
brain tumours, vascular 19 burden 4647
bypass see
coronary artery bypass deaths from 1819, 35, 46-47, food 30, 36, 62

surgery 48-49, 74 cereals 63

disability-adjusted life
years fast 68
cardiac (DALYs) 46-4-7, 74 fruit and vegetables 24, 28, 36,
defibrillation71,78, 79 economic costs of 55 62-63, 64
pacemakers 71, 78, 79 medication for 65, 71, 81 labelling
of 65, 68
rehabilitation 70 prevention of 48 legislation
O on 69
see also
coronary and heart research into 5859 processed 28
cardiovascular disease (CVD) 92 risk factors 19, 79 see also diet

deaths from 18, 74 costs see economic costs future 74-75

life
disability-adjusted years
(DALYs) 74 deaths from gender differences 25, 27, 2829,
investigations
for 75 cardiovascular disease 18, 74 32-33,42-43,81;
economic costs of 5 5 coronary heart disease 1819, 35, see also women
medication for 65, 71, 75, 77 48-49, 74

111
 medical professionals 42, 62, 65 carotid stenosis 52
genetic
disposition 19, 25,48, 81 medication 42, 54-55, 62, 65, 71 75, ,
deaths from 18-19,48, 50-51,
science 75 77,81 52-53, 74
therapy 8 1 mental health 19, 25 disability-adjusted life
years
see also
heredity
MET (metabolic equivalent) 35, 93 (DALYs) 505 1

motor vehicles 3435 economic costs of 5455

HDL-cholesterol see cholesterol, myocardial infarction see heart attack medication for 65, 71 ,
80
HDL research into 58-59
health see also education, health and nutrition see food and diet risk factors 19, 63, 79, 80
mental health and public health young people 5 1

and tobacco use, health warnings obesity 19, 24-25, 26, 34, 36-37, surgery see
coronary artery bypass
health care 41,42, 62, 65, 66, 79, 80, 93 surgery and open heart surgery
access to 40 economic costs of 5455, 75 and cardiovascular disease surgery
o J
economic costs of 54 55 open heart surgery 71,79
heart 1 8 operations 71 technology 70-71 75, 77-81
,

attack 30, 32, 93 organizations 6061 thrombosis see deep venous thrombosis
catheterization 71, 78 tobacco use 19, 24-25, 26-27,

congenital disease
1 9 physical activity and inactivity 32-33, 40-41, 42-4-3, 48, 50,
failure, congestive 92 19, 24-25, 26-27, 28, 34-35, 52, 62, 74, 79, 80, 81

inflammatory disease 1819, 81 40, 42-4-3, 48, 54, 62-63, 66, deaths from 74
muscle 18-19, 77 78,79,80,81,93 economic costs of 5455
transplantation 71, 75, 79, 81 policies 6869 health warnings about 68
tumours 19 poverty 19, 20 knowledge of risks 3233
valves 19, 20, 71, 76, 79 prevention see cardiovascular disease,
legislation
on 69
cardiac and coronary and prevention of
see also
passive smoking 32, 62
hypertensive heart disease public health prevalence of 27, 33, 75
heredity 25, 42 see also genetic initiatives 6465 quitting smoking 33, 62 63, 67
homocysteine levels in blood 68-69
policy smoke-free areas 6869, 81

25,93
19, pulmonary embolism 1 9 transplant see heart transplantation
hormone replacement therapy treatment 64-65, 70-71, 75, 80
19, 25,42-43 Quit and Win 67 triglycerides 30, 42, 80,
93
hypertension 28
see also blood race see ethnicity and race United Nations Conventions and
pressure, high
hypertensive heart disease rehabilitation 70 Goals 75
deaths from 18, 48 research 58^59, 75, 76-81
see also blood pressure, high rheumatic fever 20, 78, 93 vascular disease, peripheral 92
rheumatic heart disease 19, 20 21 ,
93
inactivity see physical activity and deaths from 18, 20-21 women 25, 28-29, 30, 32-33, 42-43

inactivity risk factors 19,

24-43, 55, 62-63, World Congresses of Cardiology 60
International Conferences on 66-67, 79, 80 World Health Assembly 68, 81
Preventive Cardiology 60 World Health Organization 60-6 1
,

International Heart Health salt intake 28, 52, 63, 65 79, 81

Conferences and Declarations 6 1 ,
schools Framework Convention on
64, 66-67, 81 health education in 66 Tobacco Control 68-69, 81

smoking see tobacco use Global School Health Initiative 66

labelling
see food socioeconomic status 25, 34, 4041, Global School-based Student
LDL-cholesterol see cholesterol, LDL 52 Health Survey 66
left ventricular
hypertrophy 25 sphygmomanometer 78 Global Strategy on Diet, Physical
legislation 68-69 statins 65, 81
Activity and Health 8
1

Iipids25, 26, 30-31, 34, 52,93 stent see

coronary stent World Heart Days 66-67, 81
lowering medication 40, 71 streptococcal infection 19, 20 World Heart Federation 60, 66-67,
see also cholesterol stress 25, 34, 40, 42, 62, 77 79
stroke 19, 20, 30, 32, 34, 50-53, World Stroke Congresses 61
76, 78, 80, 93
burden 50-5 1 youth see children and youth

112
 "Heart disease and stroke rob too many people of
precious years of quality life. This one-of-a-kind
atlas serves as a key resource for those on the
frontlines of health. " Dr Julie Gerberding, Director,
Centers for Disease Control and Prevention, Atlanta, Georgia, USA

"We applaud the authors for producing such a

comprehensive document in such a user-friendly
format." World Heart Federation

Heart disease can no longer be seen as the problem of overworked,

overweight middle-aged men; in today's world, we are all - women

and children too - at risk. One in three deaths worldwide
-17 million deaths each year - is due to cardiovascular disease.

These full-colour maps and graphics illustrate

Trends in cholesterol levels in Beijing,

Mean total cholesterol in people aged 25-64 year

the wide range of issues relating to this global 1984- 1999
mmol/l

epidemic, including:

Men
Risk factors:
high blood pressure, tobacco, inactivity, 4.15

obesity, lipids, diabetes *

1984

Women, childhood and youth Front cover photograph:

Amy, Hong Kong Guy Nowell
The global burden of Back cover photographs:
cardiovascular disease Cardiology operation, Mauritius
e

WHO/Harry Anenden;
Man selling vegetables, India
Research WHO/ Pierre Virot; Man on bencl
iStock/Tomaz Levstek; Woman
and girl buying sweets, India *
Prevention WHO/Pierre Virot; Bowl of rice
Hemera Photo-Objects
Policies and legislation Cover design: Corinne Pearlman

Treatment

o
The future
m a myriad edition

ISBN 92 4 156276 8

World Health Organization

www.who.int 9 789241 562768